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AN    INQUIRY 


DIFFICULTIES  ENCOUNTERED 


REDUCTION  OF  DISLOCATIONS  OF  THE  HIP. 


BY 


OSCAR  H.  ALLIS,  M.D., 


FELLOW  OF  THE  COLLEGE  OF  PHYSICIANS  AND  OF  THE  ACADEMY  OF  SURGERY,  PHILADELPHIA  ; 
FELLOW  OF  THE  ACADEMY  OF  SUPvGERY,   ALTOONA  ;    HONORARY  MEMBER  OF  THE 
PATHOLOGICAL   SOCIETY  OF  HARRISBURG  ;    MEMBER  OF  THE  AMER- 
ICAN SURGICAL   ASSOCIATION   AND   OF  THE   AMERICAN 
MEDICAL  ASSOCIATION  ;  SURGEON  TO  THE 
PRESBYTERIAN   HOSPITAL. 


THE  SAMUEL  D.  GROSS  PRIZE  ESSAY. 


PHILADELPHIA: 

1896. 


DOR X AN,     PRIXTEK, 
PHILADELPHIA. 


THIS    LITTLE    VOLUME    IS    DEDICATED 
TO 

Dr.  W.  C.  B.  FIFIELD 

OF  DORCHESTER  MASSACHUSETTS 

WHOSE   CORDIAL,   EARNEST   EXPRESSIONS   OF   APPRECIATION 

AND   APPROVAL   FOR   MANY   YEARS   HAVE   BEEN   A 

SOURCE  OF  GRATEFUL  ENCOURAGEMENT 

TO    THE 

AUTHOR  IN  HIS  WORK 


1429  Walnut  Street, 
Philadelphia,  February  5.  1895. 
Oscar  H.  Allis,  M.D. 

My  dear  Doctor  :  As  Chairman  of  the  Trustees  of  the  S.  D.  Gross  Fund 
and  Library  of  the  Philadelphia  Academy  of  Surgery,  I  have  the  pleasure  to 
inform  you  that  the  prize  of  one  thousand  dollars  has  been  awarded  you  for 
the  best  original  essay  among  those  entered  for  competition  January  1,  1895. 

Permit  me  to  offer  my  congratulations  upon  the  success  you  have  achieved,  and 

believe  me 

Very  truly  yours, 

J.  EwixG  Mears, 

Chairman. 
J.   EwiXG  Mear-S, 
W.  W.  Keen, 
John  Ashhurst,  Jr., 

Trustees  of  Gross  Fund  aud  Library. 


The  conditions  annexed  by  the  testator  are  that  the  prize  "  shall  be  awarded 
every  five  years  to  the  writer  of  the  best  original  essay,  not  exceeding  one  hun- 
dred and  fifty  printed  pages  octavo  in  length,  illustrative  of  some  subject  in 
surgical  pathology  or  surgical  practice,  founded  upon  original  investigations, 
the  candidates  for  the  prize  to  be  American  citizens." 

It  is  expressly  stipulated  that  the  successful  competitor  shall  publish  his  essay 
in  book-form,  and  that  he  shall  deposit  one  copy  of  the  work  in  the  .Samuel  D. 
Gross  Library  of  the  Philadelphia  Academy  of  Surgery. 


REMINISCENCES. 


In  one  of  my  visits  to  the  Presbyterian  Hospital  in  July,  1873,  I 
found  a  man  suffering  from  a  recent  dorsal  dislocation  of  the  femur. 
He  had  walked  in  his  sleep  from  a  second-story  window,  and  in  his 
descent  had  struck  a  clothes-line,  which  changed  the  direction  and 
possibly  modified  the  severity  of  the  fall.  In  the  erect  posture  the 
deformity  was  pronounced  and  typical ;  the  right  knee  bent  strongly 
inward  toward  its  fellow,  the  foot  turned  inward,  and  the  great  toe 
could  with  difficulty  be  made  to  touch  the  floor.  After  full  anaes- 
thesia the  patient  was  placed  upon  the  floor,  and  various  ineff"ectual 
efibrts  were  made  to  reduce  the  dislocation.  Reduction  was  finally 
accomplished  by  traction  upward. 

This  was  the  first  dislocation  that  I  had  ever  seen,  and,  instead  of 
being  elated  at  my  success,  I  was  rather  deeply  mortified  to  think 
that  success  had  crowned  efforts  put  forth  with  no  clear  understand- 
ing of  the  nature  of  the  accident  or  of  the  proper  steps  to  repair  it. 
I  accordingly  determined  to  lose  no  time  in  familiarizing  myself 
with  this  subject,  and,  procuring  Bigelow  on'  The  Hip,  I  took  it 
with  me  to  the  dissecting-room,  and  there  wrought  out,  over  and 
over  again,  the  problems  of  that  justly  celebrated  monograph. 
Having  satisfied  myself,  and  thinking  that  I  would  profit  by  a 
demonstration,  I  invited  the  members  of  my  quiz  class  to  the 
dissecting-room,  and  readily  convinced  them,  as  I  myself  Avas  fully 
convinced,  that  a  knowledge  of  the  Y-ligament  was  all  that  was 
necessary  to  enable  one  to  diagnosticate  or  restore  any  form  of  dis- 
location at  the  hip-joint.     My  class  was  so  well  pleased  with  the 


vi  REMINISCENCES. 

demonstration  that  I  was  induced  to  repeat  my  work  with  another 
class  a  year  later. 

Although  this  was  more  than  twenty  years  ago,  1  recall  the  pleasure 
and  satisfaction  the  work  afforded  me  as  vividly  as  if  it  were  but  yes- 
terday. I  speak  of  the  pleasure,  for  it  was  an  entirely  new  field  to 
me;  of  the  satisfaction,  because,  whatever  I  might  lack  in  other 
departments  of  surgery,  of  this  I  was  confident,  that  Bigelow  knew 
all  about  the  hip     .     .     .     and  that  I  knew  as  much  as  Bigelow. 

Six  years  passed  by  before  I  had  an  opportunity  of  putting  my 
new  attainment  to  a  test ;  with  what  result  will  be  seen  in  the  history 
of  the  following  case  : 

Simultaneous  Dislocation  of  both  Hips.  Peter  J.,  colored, 
aged  forty-two  years.  While  removing  ballast  from  the  hold  of  a  ship 
a  mass  of  earth  and  stone  fell  upon  him,  partly  burying  him.  He  was 
removed  in  a  condition  of  extreme  shock,  and  was  taken  home.  After 
a  few  weeks  he  was  able  to  crawl  out  of  bed,  and  later  on  was  taken 
from  one  hospital  to  another,  but,  as  he  would  not  consent  to  what  was 
deemed  best,  he  was  always  refused  admission.  Finally,  eighty-one 
days  after  the  accident,  he  appeared  at  the  Howard  Hospital,  at  the 
clinic  of  Dr.  Livingston,  who  detected  a  dislocation  of  the  hip,  and 
referred  him  to  Dr.  Willard,  then  in  charge  of  the  surgical  clinic. 
On  the  following  Saturday  I  met  my  colleague,  Dr.  Willard,  who 
etherized  the  patient,  and  in  a  few  seconds  reduced  by  manipulation 
a  typical  dorsal  dislocation  of  the  left  femur.  The  head  went  into 
the  socket  with  the  sound  so  characteristic  of  successful  reductions, 
and  with  the  immediate  restoration  of  normal  appearance.  But 
when,  to  satisfy  ourselves  fully  of  the  symmetry  of  the  limbs,  we 
compared  them,  the  restored  (left)  limb  was  found  markedly  shorter 
than  its  fellow.  This  discrepancy  threw  grave  doubt  upon  the  suc- 
cess of  the  reduction  ;  and  the  doubt  was  increased  when  a  distin- 
guished surgeon,  standing  by,  pointed  out  a  fulness  in  the  thyroid 
region  of  the  right  limb  that  was  absent  in  the  one  we  supposed  had 
just  been  successfully  treated.     To  remove  all  doubt,  Dr.  AVillard 


REmXISCEXCES.  vii 

redislocated  the  femur,  and  by  manipulation,  as  in  the  first  instance, 
restored  the  head  vvitli  the  audible  thud  so  clear  and  the  disappear- 
ance of  deformity  so  sudden  and  complete  as  to  dispel  every  misgiv- 
ing as  to  the  success  of  the  manipulation.  Then  for  the  first  time 
there  flashed  across  our  minds  a  full  appreciation  of  the  situation. 
Both  femurs  had  been  simultaneously  dislocated.  Dr.  Willard  had 
restored  the  left  femur,  the  right  still  lay  in  the  thyroid  depression, 
thus  enabling  us  to  account  for  the  fulness  already  alluded  to,  and 
the  apparent  lengthening. 

This  being  decided  upon,  Dr.  Willard  attempted  reduction  of  the 
right  luxation,  but  failed,  and  sent  the  patient  to  the  Presbyterian 
Hospital,  as  there  were  no  beds  at  the  Howard  Hospital  at  the  time. 
The  patient  then  came  under  my  care,  and  on  the  following  Monday 
I  was  met  by  Dr.  Willard,  and  my  colleagues,  Dr.  Porter  and  Dr. 
Reed,  and  an  earnest  but  fruitless  attempt  was  made  at  reduction. 
A  few  days  later  Dr.  Porter  and  Dr.  Hodge  assisted  me  in  a  second 
attempt.  Manipulation,  leverage,  pulleys,  and  horizontal,  oblique, 
and  vertical  traction  were  employed,  but  to  no  purpose.  The  head 
moved  freely  in  all  directions ;  it  passed  from  the  thyroid  region 
backward  to  the  dorsal,  and  from  the  dorsal  again  to  the  thyroid,  and 
could  be  made  to  approach  the  rim  of  the  socket,  but  could  not  be 
made  to  pass  over  it. 

Had  there  been  in  this  case  only  an  irreducible  thyroid  dislocation, 
I  would  have  felt  no  special  disappointment  at  not  being  able  to  reduce 
it,  since  the  time-honored  apologies  for  failure  would  have  abundantly 
satisfied  me.  The  time  during  which  the  dislocation  had  persisted 
was  now  eleven  weeks,  and  this,  I  would  have  argued,  was  ample  for 
the  filling  up  of  the  socket  and  for  the  capsule  to  close  in  around  it. 
But  no  such  argument  could  be  urged  in  view  of  the  fact  that  the 
socket  on  the  left  side  had  not  filled  up,  and  that  the  capsule  there 
presented  no  greater  obstacle  to  reduction  than  is  found  in  recent  dis- 
locations. The  left  hip  had  entered  with  an  audible  thud,  and  this 
was  good  evidence  that  the  socket  was  empty  and  covered  with  glis- 


Vlll 


REMIXISCEXCES. 


tening,  unaltered  cartilage.  The  left  femur  had  been  easily  and  in- 
stantly restored  by  manipulation  in  skilful  hands,  the  right  resisted 
the  skill,  not  only  of  Dr.  Willard,  but  also  that  of  the  entire  surgical 
staff  of  the  Presbyterian  Hospital,  even  when  that  skill  was  supple- 
mented by  the  most  approved  surgical  appliances. 

This  experience  led  me  to  suspect  that  I  had  overlooked  some  im- 
portant principle  in  my  dissections  and  experimental  work,  though 
not  doubting  for  a  moment  the  infallibility  of  Bigelow's  principles  of 
reduction  :  I  therefore  again  repaired  to  the  dissecting-room,  where 
I  carefully  and  deliberately  reviewed  the  teachings  of  this  author. 
This  work  inspired  in  me  new  confidence,  though  it  developed  no 
new  principle. 

Again  I  became  impatient  to  test  the  system,  confident  now  that 
future  triumphs  would  amply  atone  for  my  first  somewhat  mortifying 
failure.  How  much  of  a  triumph  my  next  case  proved  will  appear 
in  the  following  history  : 

Recent  Dorsal  Dislocation  of  the  Left  Hip.  Mr.  F.,  a 
middle-aged  man,  had  his  left  leg  caught  in  the  wheel  of  a  wagon 
drawn  by  oxen.  He  was  riding  between  the  wheels  and  the  oxen 
were  walking.  The  accident  occurred  March  27, 1884.  Dr.  P.  R. 
Koons  saw  the  man  about  two  hours  after  the  accident.  There  was 
an  apparent  shortening  of  from  two  and  a  half  to  three  inches.  The 
head  of  the  femur  was  in  the  position  of  high  dorsal  displacement ; 
the  knee  was  rotated  strongly  inward  with  marked  adduction. 
Several  efforts  at  reduction  were  made  by  Dr.  Koons,  with  and 
without  ether,  and  at  each  attempt  the  deformity  disappeared  to  a 
very  great  degree.  There  remained,  however,  after  each  attempt  a 
considerable  degree  of  flexion  of  the  thigh  upon  the  pelvis.  Dr. 
Koons  accordingly  brought  his  patient  to  the  Jefferson  Medical 
College  Hospital  on  March  30th,  and  through  the  courtesy  of  my 
colleague,  Dr.  W.  Joseph  Hearn,  the  man  was  placed  in  my  charge. 

Upon  examination  I  found  no  marked  deformity.  The  thigh  was 
slightly  flexed  upon  the  pelvis,  and  the  knee,  a  little  flexed,  rose 


REMINISCENCES.  ix 

above  the  level  of  the  mattress.  When  the  knee  was  depressed  it 
sprung  upward  again. 

On  April  11th,  two  weeks  after  the  accident,  assisted  by  Professor 
Gross,  Dr.  Hearn,  Dr.  Barton,  and  Dr.  Koons,  after  full  anaesthesia, 
I  began  the  examination  of  the  limb.  Upon  flexing  and  rotating  it, 
it  suddenly  changed  its  position  and  displayed  all  the  signs  of  a 
dorsal  dislocation.  The  knee  was  semiflexed  and  bent  strongly  in, 
and  rested  upon  the  right  thigh  above  the  other  knee.  All  the 
signs  were  typical  of  a  dorsal  displacement.  I  accordingly  flexed 
the  leg  on  the  thigh,  the  thigh  on  the  pelvis,  carried  the  knee 
inward,  then  upward  toward  the  umbilicus,  then  with  an  outward 
sweep  brought  it  down  in  extension.  The  result  was  that  the  head 
went  suddenly  into  a  position  in  the  neighborhood  of  the  socket 
with  all  the  apparent  signs  of  reduction,  except  that  there  were  per- 
sistent flexion  of  the  thigh  on  the  pelvis  and  a  tilting  forward  of  the 
knee.  All  present  exclaimed  that  the  reduction  was  effected,  but  I 
pointed  out  the  slight  but  ominous  symptom,  and  insisted  that  there 
was  still  a  radical  defect,  and  that,  while  the  head  of  the  femur 
might  lie  near  the  socket,  it  was  not  in  it.  Over  and  over  again  the 
head  was  thrown  into  the  dorsal  region,  and  attempts  were  made  by 
each  surgeon  present  to  conduct  the  head  into  the  socket  without 
any  remaining  deformity,  but  with  no  better  success.  Again,  on 
April  22d,  aided  by  Professor  Gross,  Professor  Brinton,  Dr.  Levis, 
Dr.  Hearn,  Dr.  Barton,  and  Dr.  Koons,  the  whole  work  was  care- 
fully repeated.  From  a  typical  dorsal  dislocation,  with  aggravated 
deformity,  the  limb  was  made  to  assume  suddenly  almost  normal 
relations,  and  no  eff"ort  to  convey  the  head  through  a  new  route  was 
any  more  satisfactory.  Bigelow's  plans  of  sudden  upward  jerking 
and  of  enlarging  the  capsular  rent  were  adopted,  but  the  result  of 
.one  method  was  identical  with  that  of  all  others,  and  the  poor  fellow 
was  sent  home  with  the  same  deformity  that  was  present  when  he 
was  brought  to  the  hospital. 

It  was  the  opinion  of  most  of  the  surgeons  present  that  the  head 


X  REMINISCENCES. 

was  restored ;  that  it  was  a  subluxation — a  radical  defect — from 
which  the  man  would  never  recover,  was  my  own  opinion.  The  tilting 
forward  of  the  knee  and  the  flexion  of  the  thigh,  I  knew,  should  not 
persist  after  a  satisfactory  reduction,  and  I  therefore  inferred  that 
the  head  still  lay  below  the  socket. 

As  months  rolled  by  the  condition  of  the  unfortunate  man  was 
kept  fresh  in  my  mind  by  correspondence  with  Dr.  Koons,  who 
reported  Mr.  F.  as  a  great  sufferer,  and  that  he  feared  the  prolonged 
use  of  morphine  would  lead  to  the  formation  of  the  morphine-habit. 
The  persistence  of  the  pain  confirmed  me  in  the  opinion  that  the 
limb  had  not  been  properly  restored,  but  I  thought  nothing  but  an 
autopsy  Avould  clear  up  the  mystery.  It  was  cleared  up,  however, 
much  sooner  than  I  expected,  and  in  the  following  manner : 

In  February,  1885,  nearly  a  year  after  the  incident  just  related, 
and  while  it  was  still  fresh  in  my  mind.  Dr.  Bley  and  Dr.  Johnson, 
who  had  returned  to  the  Jeiferson  Medical  College  for  post-graduate 
instruction,  requested  me  to  go  with  them  to  the  Philadelphia  School 
of  Anatomy,  then  under  the  care  of  Dr.  George  McClellan,  and  give 
them  practical  instruction  in  reducing  dislocations  of  the  hip  by 
manipulation.  After  strapping  a  cadaver  to  the  floor,  Dr.  Bley 
eff'ected  a  dorsal  dislocation  by  flexion,  adduction,  and  rotation  inward 
without  previous  tenotomy  of  the  capsule.  I  then  requested  him  to 
employ  Reid's  method.  Accordingly  he  knelt,  and  grasping  with 
one  hand  the  ankle  and  with  the  other  the  knee,  he  directed  the 
knee  inward  toward  the  upper  third  of  the  opposite  thigh  and  cir- 
cumducted it,  moving  the  knee  upward  and  outward  over  the  pubes 
and  umbilicus  and  swinging  it  outward,  and  then  brought  the  limb 
down  in  full  extension,  and  the  reduction  was  effected  as  if  by 
magic,  every  vestige  of  deformity  disappearing.  I  then  requested 
Dr.  Johnson  to  make  a  trial.  He  did  it  in  almost  every  particular, 
as  Dr.  Bley  had  done,  except  that  perhaps  he  pressed  heavily  upon 
the  knee  as  he  directed  it;  but  when  he  brought  the  limb  down  in 
extension,  instead  of  all  deformity  disappearing,  I  was  delighted  to 


REMINISCENCES.  xi 

see  the  same  deformity  present  that  persisted  in  the  case  of  Mr.  F. 
The  thigh  was  so  much  flexed  upon  the  pelvis  that  the  knee  was 
raised  about  a  foot  above  the  floor ;  the  thigh  was  also  a  little  ab- 
ducted and  rotated  outward,  with  every  manifestation  of  constraint. 
At  my  request  the  position  was  not  disturbed,  but  the  cause  sought 
for  by  dissection.  This  revealed  the  head  in  the  socket,  hut  the 
sciatic  nerve  was  stretched  over  the  neck.  Thus  I  had  been  mis- 
taken in  insisting  that  the  reduction  in  F.'s  case  was  incomplete. 
I  was,  however,  right  in  demanding  an  explanation  of  the  elastic 
forward  spring  of  the  knee  after  apparent  reduction,  and  that  con- 
dition no  one  present  could  explain. 

This  discovery  infused  new  life  into  my  study  of  dislocations  of 
the  hip,  and  I  again,  by  means  of  dissections,  reviewed  the  subject 
with  increased  interest.  One  point  I  certainly  had  gained,  and  I 
was  satisfied  that  in  all  subsequent  cases  I  would  know  when  a  dis- 
location of  the  hip  was  restored  and  when  the  great  sciatic  nerve 
was  involved.  The  vague  notion  that  the  head  had  been  prevented 
from  entering  the  socket  had  been  cleared  up,  and  I  felt  an  increas- 
ing confidence  that  I  was  now  prepared  for  any  difficulty  that  would 
present  itself 

That  this  confidence  was  no  better  founded  than  my  former  had 
been  will  appear  from  the  perusal  of  the  following  case : 

J.  H.  M. ,  aged  twenty-three  years,  a  strong,  well-developed  young 
man,  fell  on  August  18,  1885,  from  a  chestnut  tree  to  the  ground,  a 
distance  of  about  twenty-five  feet.  Dr.  Newcomet  saw  the  patient 
soon  after  the  accident,  recognized  a  dorsal  dislocation  of  the  right 
femur,  and  made,  without  ether,  an  unsuccessful  attempt  at  reduc- 
tion. Five  hours  later,  using  anaesthesia,  and  assisted  by  two  other 
physicians,  he  again  failed.  The  man  was  then  taken  to  the  Jeffer- 
son Medical  College  Hospital,  twenty-six  hours  after  the  accident, 
and  just  before  the  hour  for  the  medical  clinic.  Through  the  courtesy 
of  Prof.  Da  Costa,  I  was  permitted  to  take  the  injured  man  before 
the  class  immediately  after  his  arrival.     The  symptoms  were  those 


xii  REMINISCENCES. 

of  a  dorsal  displacement.  When  fully  etherized  the  man  was  placed 
upon  a  mattress  upon  the  floor ;  I  then  flexed  the  leg  on  the  thigh, 
the  thigh  on  the  pelvis,  and  seizing  the  ankle  with  my  right  hand, 
and  placing  the  bent  elbow  of  my  left  arm  beneath  the  popliteal 
space,  I  adducted,  rotated  inward,  lifted,  rotated  outward,  circum- 
ducting at  the  same  time,  and  brought  the  limb  down  in  extension 
to  complete  the  manoeuvre.  I  failed ;  repeated  my  efforts  ;  failed 
again  ;  and  then  asked  Professor  Brinton  to  make  a  trial.  He  did 
so  until,  exhausted,  he  reluctantly  desisted.  Prof.  Gross  then  un- 
dertook the  manipulation,  and,  after  witnessing  two  failures,  tried 
hard  not  to  make  a  third,  but  to  no  purpose.  The  man  was  then 
removed  to  an  adjoining  room,  where  Dr.  Richard  J.  Levis,  Surgeon 
to  the  Pennsylvania  Hospital,  Dr.  Hearn  and  Dr.  Barton,  Surgeons 
to  the  Jefferson  Medical  College  Hospital,  and  others  tried  long  and 
earnestly,  but  ineffectually,  to  restore  the  dislocation. 

A  week  later,  aided  by  Prof  Brinton,  Prof.  Gross,  and  Prof.  Pan- 
coast,  Dr.  Hearn,  Dr.  Barton,  and  Dr.  Reed  (the  latter,  surgeon  to 
the  Presbyterian  Hospital),  a  second  long  but  fruitless  effort  at  re- 
duction was  made. 

With  this  failure  vanished  all  the  fancied  acquisitions  of  my  re- 
peated studies  on  the  cadaver,  and  with  them  all  my  reliance  upon 
the  dogmatic  assertions  of  authors  and  teachers  upon  the  subject. 
My  disappointment  was  indeed  great.  What  I  had  regarded  as  a 
science  and  had  pursued  with  ardor  to  its  supposed  mastery  had  van- 
ished in  a  moment,  and  left  me  small  compensation  for  the  labor  and 
study  I  had  expended  upon  it.  I  had  failed  after  the  fairest  trials, 
and  had  desisted,  not  for  want  of  co-operation  on  the  part  of  my  pa- 
tients, but  for  want  of  expedients  on  my  own  part.  That  which  im- 
pressed me  more  than  anything  else  was,  not  that  I  could  not  reduce 
dislocations,  but  that  I  could  conceive  of  no  rational  cause  for  my 
inability  to  do  so. 

Again  I  went  into  the  dissecting-room,  but  found  there  no  solu- 
tion to  my  difficulties.     Other  failures,  some  in  my  own  hands  and 


REMINISCENCES.  xiii 

some  in  others,  Avliich  I  need  not  record,  confirmed  my  now  settled 
conviction  that  the  rules  for  the  reduction  of  dislocations  of  the  hip- 
joint  were  few  and  simple,  and  that  when  these  failed  in  the  hands 
of  a  novice,  he  knew  as  much  about  the  cause  of  failure  as  I  did  after 
years  of  perplexing  study.     , 

One  who  has  experienced  only  success  in  the  reduction  of  dislo- 
cations may  be  surprised  at  these  confessions,  while  he,  in  whose 
hands  reductions  have  taken  place,  that  have  resisted  previous  efforts 
in  other  hands,  may  wish  that  he  had  had  a  chance  at  those  cases. 
But  let  such  a  one  recall  the  case  of  J.  H.  M.  The  dislocation  was 
only  a  day  old,  and  I  failed  before  a  well-filled  amphitheatre.  What 
would  I  not  have  given  for  success  !  I  was  followed  by  Prof.  Brin- 
ton,  whose  office  it  was  to  teach,  and  now  he  had  an  opportunity  to 
demonstrate,  the  proper  means  to  overcome  the  obstacles  to  reduction. 
Witnessing  my  own  and  Prof.  Brinton's  failure,  would  not  Prof. 
Gross  have  enjoyed  our  discomfiture,  by  skilfully  dropping  the  head 
into  its  socket  ?  And  after  we  had  failed,  with  four  or  five  hundred 
students  as  spectators,  all  eager  for  the  result,  what  would  have  been 
the  exultation  of  Dr.  Levis,  Dr.  Hearn,  or  Dr.  Barton,  if  either 
could  have  accomplished  that  which  we  had  failed  to  do  ?^  Certainly 
there  was  every  inducement  for  each  man  to  do  his  best,  and  to  try 
some  new  expedient  after  the  previously  tried  methods  had  failed. 

Every  surgeon  is  aware  that  the  reduction  of  a  dislocation  is  usu- 
ally a  very  simple  and  easy  matter.  I  saw  an  interne  in  the  Phila- 
delphia Hospital,  fresh  from  the  lecture-room,  take  hold  of  a  recently 
dislocated  femur,  trying  to  recall  the  method  taught  by  the  Professor 
of  Surgery,  and,  before  he  had  decided  what  to  do,  and  w^hile  he  was 
aimlessly  moving  it  about,  the  head  sprang  into  its  socket  with  the 
characteristic  audible  thud.    "  I  wish  I  had  noticed  how  I  did  that," 

1  After  our  failure,  the  young  man  was  taken  home,  and,  unwilling  to  go  through  life  a 
cripple,  he  wrote  to  Prof.  D.  Hayes  Agnew,  stating  what  had  been  done  for  his  injury,  and 
asking  his  opinion  about  making  further  attempts  at  reduction  at  the  Hospital  of  the  Uni- 
versity of  Pennsylvania.  The  latter  replied  in  terms  so  complimentary  to  those  who  had 
failed  that  the  young  man  never  sought  further  advice. 


xiv  REMINISCENCES. 

was  his  regretful,  half-mortified  ejaculation.  Cases  of  restoi'ation  are 
reported  that  occurred  in  the  hands  of  experienced  surgeons,  the  re- 
turn taking  place  during  a  preliminary  examination,  and  before  any 
intelligent  effort  had  been  put  forth. 

On  page  QQ  will  be  found  the  reportof  a  case  in  which  the  patient 
was  deemed  too  ill  to  justify  an  effort  at  replacement,  but  in  which 
the  reduction  was  unwittingly  performed  by  the  nurse,  who  was  chang- 
ing the  patient's  position  in  bed.  All  such  cases  are  confirmed  by 
experimental  study  ;  for,  after  effecting  dislocations  of  the  shoulder 
and  hip  in  the  cadaver,  I  have  often  found  the  head  hovering  on  the 
confines  of  the  socket,  unwilling  to  stay  out,  and  often  returning 
spontaneously  or  upon  the  slightest  change  of  position. 

The  difference  in  different  cases  can  also  be  illustrated  from  clini- 
cal experience.  I  succeeded  in  my  first  case  before  I  had  made  any 
special  study  of  the  subject,  and  when  I  possessed  only  the  meagre 
impressions  that  students  get  from  lectures.  In  my  five  succeeding 
cases  I  failed,  though  I  had  made  the  subject  one  of  thorough  and 
oft-repeated  experimental  study.  Prof.  Brinton  failed  before  his 
class  in  the  case  of  J.  H.  M.,  whose  right  femur  had  been  displaced 
the  day  before.  He  succeeded  in  the  next  case  he  took  before  his 
class,  which  was  also  a  right  dorsal  dislocation,  in  a  young  man,  injured 
the  day  before ;  and,  to  make  the  case  still  more  nearly  analogous, 
he  succeeded  after  others  had  failed.  Dr.  Reed  failed  in  two  of  my 
cases,  but  restored  subspinous  dislocation  by  the  first  manipulation. 

The  surgeons  whose  names  I  have  mentioned  were  all  practically 
familiar  with  dislocations  of  the  femur,  and  brought  to  bear  all  the 
manoeuvres  that  a  long  hospital  experience  and  extensive  reading 
could  suggest. 

Reflection  upon  the  subject  led  me  to  believe  that  the  true  nature 
of  the  obstacles  that  occasionally  present  themselves  in  dislocations  of 
the  femur  would  always  remain  a  matter  of  doubt,  and  that  difficul- 
ties arose  in  the  living  that  had  no  counterpart  in  the  dead  subject. 

With  these  conclusions  I  had  almost  dismissed  the  subject  from 


REMINISCENCES.  XV 

my  mind  when,  in  January,  1892,  a  fatal  result  from  an  attempt  to 
reduce  an  old  thyroid  dislocation  induced  me  again  to  return  to  the 
dissecting-room,  with  the  special  design  of  studying  the  relation  of  the 
femoral  vessels  to  the  subject  of  dislocations.  I  soon  found  that  my 
early  enthusiasm  in  the  subject  had  fully  returned,  and  I  now  have 
the  satisfaction  of  saying  that  I  believe  I  have  seen  the  exact  coun- 
terpart in  the  cadaver  of  nearly  every  difficulty  that  I  have  ever  en- 
countered in  the  living  subject.  What  I  have  seen  I  have  tried  to 
depict,  tried  to  show  its  peculiar  mechanism  and  the  rationale  of 
deliverance.  Many  difficulties  that  struck  me  at  first  as  insuperable, 
and  which,  before  my  studies  were  hopelessly  inexplicable,  are  no 
longer  so.^ 

In  the  Introductory  Study  which  follows,  clinical  difficulties  have 
suggested  and  directed  experimental  work.  To  no  class  of  affections 
has  clinical  experience  contributed  so  little.  To  anaesthesia,  to  the 
knowledge  gained  from  dissection,  to  the  study  of  fatal  cases  of  trau- 
matic dislocations,  and  to  experimental  work  in  the  dissection-room  do 
we  owe  all  the  progress  we  have  made  in  this  department  of  surgery. 
The  clinic  has  really  been  the  amphitheatre  for  the  display  of  skill 
for  the  relief  of  the  living  which  was  gained  upon  the  cadaver  in  the 
dissecting-room.  Some  have  fancied  that  they  have  found  in  exper- 
imental work  the  solution  of  all  conceivable  difficulties,  and  have 
spoken  with  confidence  upon  the  subject.  For  my  part,  I  have  been 
too  often  and  too  sadly  disappointed  in  dogmatic  assertions  to  ven- 
ture upon  the  same  course  myself.  I  have  everywhere  striven  to  be 
clear  and  candid.  My  oft-repeated  failures  have  left  me  no  room  for 
boasting.  They  have  not,  however,  been  an  unmixed  evil ;  for,  while 
they  have  been  a  constant  menace  to  over- confidence,  they  have  also 
been  a  constant  spur  to  exertion. 

1  N.  B.— None  of  the  foregoing  remarks  appear  in  the  essay  as  handed  in.  All  competing 
writers  were  obliged  to  appear  incog.,  and  that  necessitated  the  omission  of  Reminiscences. 
—The  Author. 


PART  I. 


INTRODUCTORY    STUDY 


PROPOSITIONS. 


The  following  propositions  are  discussed  : 

I.  The  Capsule  is  the  most  important  agent  against   traumatic 
dislocations  of  the  femur. 

II.  For  the  laceration  of  the  capsule  and  dislodgment  of  the  head 
of  the  femur,  the  femur  is  employed  as  a  lever. 

III.  Every  lever  has  a  fulcrum ;  the  fulcra  required  in  dislocations 
of  the  femur  are  bony  and  ligamentous. 

IV.  Dislocation  by  thrust,  if  possible,  is  infrequent. 

V.  Reduction  by  Circumduction  is  the  simplest,  the  most  brilliant, 
and  the  most  hazardous  of  all  modes  of  replacement. 

VI.  Method  suggested  for  reduction  of  dislocation  of  the  head  of 
the  femur  when  associated  with  fracture  of  the  shaft. 


INTRODUCTORY  STUDY. 


ANATOMY. 

It  is  £1  matter  upon  whicli  the  medical  student  may  "well  con- 
gratulate himself,  that  the  study  of  dislocations  at  the  hip-joint 
has  been  reduced  within  a  narrow  compass.  Thus,  if  I  may  be 
permitted  to  divide  the  socket  into  three  equal  parts,  I  may  say  that 
the  havoc  to  capsule  and  muscles,  attending  dislocations,  will  almost 

Fig.  1. 


invariably  be  confined  to  the  lower  two-thirds,  while  that  portion  of 
the  capsule  lying  within  the  compass  of  the  upper  third,  as  well  as  the 
muscles  that  cover  it,  will,  with  even  greater  certainty,  escape  in- 
jury. Still  more  important  are  the  now  well-established  facts  that 
we  are  indebted  to  the  untorn  remnant  of  capsule  for  the  signs  of 
dislocation  and   for   the  most  effective  means  for  its  restoration. 


4  INTRODUCTORY  STUDY. 

Certainly  this  is  one  of  the  departments  of  surgery  in  which  the 
labor  of  centuries  is  made  readily  available  to  the  earnest  student. 
Knowledge  that  was  at  one  time  vague,  diffuse,  and  theoretical  has 
approached  the  dignity  of  fact,  and  he  who  is  willing  to  familiarize 
himself  with  the  subject  will  find  himself  able  to  do  more,  unaided, 
in  a  few  moments,  than  our  learned  Fathers  in  Surgery  could  accom- 
plish with  powerful  auxiliaries  in  hours. 


The  Pelvis. 

Throughout  the  Introductory  Studies  I  shall  speak  of  the  pelvis 
as  lying  upon  its  back.  In  this  position  we  usually  find  our  patient; 
in  this  we  administer  an  anaesthetic  and  make  our  attempts  at  reduc- 
tion ;  and  in  this  we  must  determine  our  succers  before  the  patient 
returns  to  consciousness  and  can  assume  another  posture. 

If  the  pelvis  be  placed  upon  its  back  upon  the  floor,  the  pubes 
becomes  the  highest  and  the  sacrum  the  lowest  part.  In  this  posi- 
tion the  socket  lies  about  midway  between  the  level  of  the  pubes  and 
the  floor. 


SAC/iUM 


The  situation  of  the  socket  is  of  great  practical  importance. 
Rudely  described,  a  transverse  section  of  the  pelvis  is  lozenge-shaped, 
and  at  the  extreme  right  and  left  of  the  lozenge  lie  the  sockets.  This 
position  puts  the  femur  under  the  advantageous  control  of  muscles 
that  arise  from  the  pelvis,  and  gives  the  hips  a  wide  separation  for 
a  firm  base  of  support.  The  socket  looks  upward  and  outward  :  in 
the  erect  posture,  downward  and  outward.  It  is  situated  at  the 
junction  of  two  irregular  bony  surfaces  :  the  inner,  or  pubo-ischiatic ; 
the  outer,  or  ilio-ischiatic.     These,  for  want  of  a  more  appropriate 


THE  PELVIS.  5 

name,  I  shall  denominate  the  inner  and  outer  planes.  These  meet  at 
an  angle  of  about  90°.  The  fact  that  the  bony  surfaces  recede  from 
the  socket,  permitting  it  to  stand  out  in  bold  relief,  explains  why 
the  femur  can  have  so  extensive  a  range  of  motion  without  danger 
of  bony  collision.  The  socket  lies  chiefly  upon  the  pubic  aspect  of 
the  pelvis ;  it  is  excluded  from  the  dorsal  region  by  a  high  acetabu- 
lar ridge.  The  head  of  the  femur  lies  in  the  socket ;  but  the 
trochanter  (Fig.  3)  projects  over  the  outer  rim.  The  retentive 
apparatus  exerts  its  influence  chiefly  upon  the  head ;  the  motor 
power  is  attached  to  the  trochanter  and  the  shaft  of  the  femur. 

Fig.  3. 

POBES 


Planes  of  the  Pelvis.  I  have  alluded  to  the  anatomical  fact 
that  the  socket  lies  at  the  junction  of  two  irregular  bony  surfaces 
or  planes.  These  planes  are  caused  by  a  sharp  bend  in  the  in- 
nominate bone,  which,  while  it  gives  great  prominence  to  the  socket, 
makes  the  planes  of  the  bony  surfaces  very  distinct  from  each  other. 
The  ridge,  or  dividing-line,  between  these  two  planes,  passing  from 
the  superior  spine  through  the  tuberosity  of  the  ischium  (Fig.  4,  X, 
Y),  divides  the  sockets  into  two  nearly  equal  parts.  If  the  head 
escapes  upon  the  inner  plane — no  matter  where — the  whole  lower 
extremity  will  present  an  entirely  different  series  of  phenomena  from 
those  of  a  dislocation  upon  the  outer  plane.  Thus,  at  the  outset,  I 
am  led  to  give  great  stress  to  the  anatomical  shape  of  the  pelvis,  as 
it  gives  us  a  rational  classification  of  all  dislocations  into  Outward 
and  Inward. 

After  the  occurrence  of  a  dislocation  outward  the  socket  can  some- 
times, in  thin  persons,  be  faintly  outlined.  The  fingers  are,  however, 
prevented  from  sinking  into  it  by  the  remnant  of  untorn  capsule 
and  the  tendon  of  the  ilio-psoas  muscle,  which  are  drawn  obliquely 


6  INTROD  UCTOR Y  STUD  Y. 

and  quite  tensely  across  it.  This  muscle  is  relaxed  by  flexion  under 
normal  conditions  ;  but  after  dorsal  dislocation  a  part  of  the  weight  of 
the  limb  would  fall  upon  it,  put  it  on  the  stretch,  and  prevent  the 
examiner  from  closely  defining  the  socket.  If  the  socket  can  be  dis- 
tinctly outlined,  the  dislocation  is  outward  ;  it  cannot  be  inward.  The 
socket  is  deeply  excavated  at  the  expense  of  the  ilium,  ischium,  and 
pubes.  I  should  not  say  at  the  expense  of  it,  for  the  equivalent  of 
bony  material  is  simply  transferred  from  the  middle  to  the  periphery 
of  the  socket.  Thus  a  rim  is  formed,  raised  above  the  level  of  the 
bone,  which  serves  as  a  barrier  against  displacement,  and  may  also 


Fig.  4. 


y  ••. 


constitute  a  formidable  barrier  to  reduction.  The  tendency  of  the 
head,  in  the  normal  functions  of  the  joint,  is  to  displacement  up- 
ward and  outward ;  but  this  tendency  is  so  fully  and  effectually 
guarded  against  by  the  depth  of  the  socket  and  the  unusual  strength 
of  the  capsule  in  this  particular  region  that  dislocations  in  this 
quarter  are,  if  possible,  certainly  very  infrequent. 

As  no  part  of  the  socket  is  better  guarded  against  displacement 
than  the  upper  and  outer,  so  no  part  is  better  able  to  resist  fracture. 
Fracture  of  the  rim  of  the  acetabulum  is  very  infrequent.  It  is 
sometimes  thought  to  be  present  when  the  head,  after  reduction, 


THE  PELVIS. 


readily  becomes  re-dislocated ;   but  this  may  be  occasioned  by  a 
socket  partly  filled  by  muscle  and  capsule. 

Security  of  the  Socket.  An  interesting  study  in  connection 
with  the  socket  is  the  mechanism  through  which  nature  has  com- 
bined great  freedom  of  motion  with  the  greatest  possible  security. 
Were  the  head  held  in  the  socket  at  all  times  by  its  ligaments,  then 
its  ligaments  must  always  be  tense,  and  the  area  of  motion  would  be 
very  limited  ;  with  a  large  universal  range  of  motion  the  capsule 
can  have  no  retentive  function,  except  as  a  check  to  transgression. 


Fig.  5. 


Fig.  6. 


In  normal  limits  a  retentive  function  largely  independent  of  capsule 
must  be  invoked,  and  this  Weber  has  shown  to  be  atmospheric 
pressure.  To  accomplish  this  a  firm  yielding  cartilage,  known  as 
the  cotyloid  ligament,  is  strongly  attached  to  the  rim  of  the  bony 
socket.  By  this  method  the  socket  is  deepened  and  the  joint  is 
secured  against  the  possibility  of  dislocation  in  its  ordinary  range  of 
motion.  Had  the  socket  been  deepened  by  a  bony  instead  of  a  car- 
tilaginous rim,  the  range  of  motion  would  have  been  abridged  and 
the  danger  of  fracture  of  the  rim  or  femur  would  have  been  increased 
manifold.  Weber  showed  that,  after  the  entire  capsule  had  been 
removed,  it  became  a  problem  of  mechanics  to  draw  the  head  from 
the  socket.  From  this  function  the  cotyloid  ligament  is  often  called 
the  sucker  ligament. 

Although  the  capsule,  as  a  ligament,  has  no  retentive  function 
during  the  ordinary  movements  of  locomotion,  it  must  not  be  in- 
ferred that  the  security  of  the  joint  is  wholly  attributable  to  atmos- 
pheric pressure.  On  the  contrary,  the  joint's  security  is  largely 
due  to  muscular  action.     Thus  the  gluteus  minimus  and  the  iliacus 


8  INTROD  UCTOR Y  STUD Y. 

internus  have  insertions  into  the  upper  half  of  the  capsule  which  add 
directly  to  its  thickness  and  strength,  while  at  the  same  time  they 
act  as  tensors  of  the  capsule.  The  psoas  magnus  is  attached  partly 
to  the  capsule,  though  in  the  main  it  passes  over  the  part  of  the 
capsule  that  is  especially  called  upon  to  make  pressure  upon  the 
head  of  the  femur.^  Thus,  while  the  capsule  in  itself  is  a  fibrous 
structure,  it  becomes,  under  the  action  of  these  three  powerful  mus- 
cles, an  active  barrier  against  displacement.  At  every  step  a  man 
makes,  the  head  of  the  femur  rises  from  the  bed  of  the  socket  and 
tends  toward  displacement.  Such  a  rising  would  produce  a  vacuum 
between  the  head  and  socket,  the  direct  effect  of  which  would  be 
to  impede  capillary  circulation  in  the  bed  of  the  socket,  were  there 
not  a  special  provision  against  it.  Such  a  mechanism  designed  to 
equalize  pressure  exists.  Beneath  the  inner  border  of  the  cotyloid 
cartilage  there  is  a  canal  leading  to  the  central  dome  of  the  socket. 
This  canal  is  filled  with  loose  connective  tissue,  through  which  the 
vessels,  nerves,  and  lymphatics  find  their  way.  Now,  this  loose, 
movable,  fatty  material  acts  as  an  automatic  valve  or  piston,  sinking 
into  the  canal  whenever  there  is  intra-acetabular  exhaustion,  and 
bulging  forth  when  this  condition  is  relieved,  thus  preventing  any 
disturbances  from  altered  atmospheric  pressure,  Avhich  otherwise 
must  take  place  with  every  step.  I  have  noticed  a  similar  bulging 
and  recession  of  the  loose  connective  tissue  beneath  the  web  in  the 
ischio-femoral  band ;  but  such  a  function  is  hardly  necessary  in  the 
extra-cotyloid  portion  of  the  articulation.  The  retentive  apparatus 
of  the  hip  is,  therefore,  a  complex  and  widely  distributed  mechanism. 
It  embraces  the  capsule  when  the  head  tends  to  pass  beyond  its 
normal  limits,  the  psoas  and  iliacus  when  the  joint  is  in  active  service, 
the  fascia  lata,  and  atmospheric  pressure.  This  provision  has  a 
wider  range  than  might  be  at  first  supposed,  for  when  the  poor 
hemiplegic  is  bereft  of  all  muscular  support  the  security  of  the 
joint  is  still  preserved  by  ligaments  and  atmospheric  pressure. 

The  Head  of  the  Femur. 

We  are  very  apt  to  associate  the  security  of  the  head  of  the  femur 
with  the  depth  of  the  socket,  but  the  truth  is  that  in  every  useful 

1  The  retentive  function  of  the  fascia  lata  wiU  be  discussed  in  its  appropriate  place. 


THE  LIGAMENTUM  TERES. 


9 


position  little  more  than  half  the  head  lies  in  contact  with  the  socket. 
The  diagram  (Fig.  7)  represents  the  upper  half  of  the  head  entirely 
outside  the  bony  socket  and  the  lower  quite  within  it.  Indeed,  the 
positions  in  which  the  head  would  seem  most  secure  are  those  in 


Fig.  7. 


which  the  femur  is  least  serviceable.  The  reader  will  note  that  when 
a  part  of  the  head  is  within  the  bony  socket  the  neck  does  not  come 
in  contact  with  the  rim  ;  and  this  is  true  of  all  normal  movements  of 
the  joint. 

The  Ligamentum  Teres. 

The  ligamentum  teres  is  described  as  a  tubular  structure  of  vari- 
able  size  and  shape,  extending  from  the  dome  and  inner  margin  of 
the  socket  to  the  dimple  in  the  head  of  the  femur.  It  is  covered 
with  synovial  membrane  reflected  from  the  fatty  cushion  in  the 
depths  of  the  socket.  A  small  vessel  runs  throughout  its  length, 
distributing  its  branches  on  the  periphery  of  the  ligament.  Accord- 
ing to  Gray  (who  quotes  Struthers),  "  the  teres  checks  rotation 
outward  and  adduction  of  the  flexed  femur ;  it  assists  in  preventing 
dislocations  of  the  femur  forward  and  outward,  an  accident  likely 
to  occur  from  the  necessary  mechanism  of  the  joint,  if  not  provided 
against  by  this  ligament  and  the  thick  anterior  part  of  the  capsule." 
This  statement  is  very  generally  accepted  by  the  profession.  As  a 
theory,  it  is  comprehensive  and  almost  challenges  a  misgiving.  For 
my  part,  I  join  the  few  who  believe  that  there  are  no  adequate 
grounds  for  calling  this  a  ligament.  Were  it  as  strong  as  steel  the 
mechanism  is  such  that  it  must  rupture  or  tear  loose  from  its  attach- 
ments whenever  called  upon  to  prevent  a  dislocation.     Indeed,  the 


10  INTRODUCTORY  STUDY. 

ligament  rarely  separates  from  the  bead,  but  instead  brings  away  a 
thin  lamina  of  bone.  Hence,  were  the  structure  ten  times  stronger 
than  it  is,  the  bones  themselves  must  be  proportionately  stronger  or 
it  would  avail  nothing. 

The  teres  is  absent  in  the  orang-outang,  in  the  anthropomorpha, 
and  in  the  South  American  sloth.  These  animals  display  their 
wonderful  activities  in  trees,  moving  from  branch  to  branch  and 
from  tree  to  tree  with  astonishing  rapidity ;  and  if  any  animal 
required  a  teres  to  establish  a  secure  hip-joint,  certainly  it  would  be 
present  in  these.  It  is  also  absent  in  the  elephant,  and  sometimes 
it  is  absent  in  man. 

The  alleged  functions  of  the  teres  as  a  ligament  are  : 

1.  To  check  a  tendency  to  dislocations  ; 

2.  To  suspend  the  head  of  the  femur  as  in  a  sling,  to  prevent 
shocks  in  runnincj  and  walking  ; 

3.  To  act  as  a  channel  of  nutrition  to  the  head  of  the  femur. 

4.  It  is  alleged  by  Bland-Sutton  that  the  structure  has  no  special 
function  now,  and  is  merely  a  retrogression  from  the  pectineus 
muscle. 

Unlike  the  foregoing  theories,  and  possibly  no  better  than  the 
poorest,  is  my  own,  viz.,  that  the  teres  when  present  is  an  accessory 
lubricating  agent  to  the  joint.  The  chief  source  of  synovia  to  the 
head  is  from  the  synovial  membrane  that  covers  the  fatty  cushion 
in  the  dome  of  the  socket.  Continuous  with  this  is  the  teres  cov- 
ered by  a  reflection  of  the  synovial  membrane.  To  this  membrane, 
and  not  to  the  head  of  the  femur,  the  artery  that  enters  the  base  of 
the  teres  is  distributed.  Were  it  not  for  the  special  provision  of  a 
fatty  cushion,  covered  with  a  synovial  membrane,  for  lubricating  the 
head,  all  the  synovia  must  be  pumped  up  by  the  action  of  rotator 
and  other  muscles^  that  compress  the  capsule,  and  in  man  in  the 
erect  posture  gravitation  would  carry  the  lubricant  away  from  and 
not  toward  the  articulating  surface.  It  will  be  remembered  that  the 
dome  of  the  socket  is  covered  with  a  loose  fatty  cushion,  and  such  a 
construction  may  be  designed  to  enable  it  to  follow  the  head  through 
the  suction  which  its  slight  tendency  to  displacement  creates,  giving 
it  the  function  of  a  swabber  to  the  movable  head,  while  the  liga- 


•  The  psoas,  gluteus  minimus,  and  small  rotators  are  the  regulators  of  the  cai>sule,  and  no 
doubt  contribute  to  the  distribution  of  the  synovia. 


THE  LIG AMENTUM  TERES.  H 

mentum  teres,  lying  flat  upon  it,  may  have  the  additional  function 
of  distributing  synovia. 

Tears  from  the  Head.  I  think  the  ligamentum  teres  must 
vary  in  length.  I  have  cut  away  the  capsule  on  its  inner  aspect 
and  dislodged  the  head  by  abduction  upon  the  inner  border. of  the 
socket  without  rupturing  the  teres,  and  at  other  times  I  have  torn  it 
completely  oflF  from  the  head  in  eiforts  at  dislocation,  and  on  dissec- 
tion have  found  the  head  in  the  socket  and  the  capsule  not  sufficiently 
torn  to  permit  the  head  to  escape  from  the  socket.  From  experi- 
mental work  I  am  quite  disposed  to  think  that  the  teres  is  often 
ruptured  in  severe  wrenches  of  the  hip,  which  may  tear  the  capsule, 
but  fall  short  of  complete  dislocation. 

In  my  experiments  it  has  been  interesting  to  watch  the  teres  tear 
from  the  head  of  the  femur.  It  is  a  fact,  based  upon  the  lesions  of 
fatal  traumatic  dislocations  and  verified  by  work  in  the  dissecting- 
room,  that  this  structure  is  usually  torn  from  the  head  of  the  femur 
— rarely  from  the  socket  or  in  its  continuity.^  If  the  inner  part  of 
the  capsule  be  removed  and  the  thigh  be  abducted,  the  head  will 
gradually  emerge  from  the  socket,  closely  surrounded  by  the  sucker 
ligament  (Fig.  8),  which  hugs  the  yet  unbroken  teres  closely  against 

Fig.  8.  Fig.  9. 

T£/f£S 


the  head  of  the  femur.  As  the  head  rises,  traction  is  made,  not  on 
all  the  fibres  at  once,  but  upon  the  uppermost  fibres  only.  (Fig.  9.) 
These  fibres  are  the  first  to  yield,  after  which  the  stress  falls  upon 
succeeding  fibres.  Hence  the  attachment  of  the  teres  to  the  head  is 
its  weakest  part  in  accidents  like  dislocations  ;  because  the  violence 
explodes  upon  the  fibres  separately  and  upon  the  most  distant  ones 
first.  A  very  common  mode  of  separation  is  for  the  teres  to  bring 
with  it  a  thin  lamina  of  bone  from  the  head.    The  lamina  tears  from 

1  I  have  seen  it  tear  through  the  middle  and  also  from  its  acetabular  attachments.  In  two 
cases  in  which  the  teres  remained  attached  to  the  head  it  had,  by  its  pelvic  attachments, 
torn  the  transverse  ligament  up  by  the  roots  and  dragged  it  out  of  the  socket. 


1 2  INTROD  UCTOR  Y  STUB  Y. 

the  bone,  beginning  always  at  the  upper  or  most  distant  part,  thus 
demonstrating  that  the  strain  is  greatest  at  this  point  and  that  the 
strain  does  not  fall  equally  upon  the  fibres  under  such  a  test.  It 
makes  no  difference  whether  the  dislocation  is  primarily  inward  or 
outward — the  teres  tears  in  the  same  manner  from  the  head  ;  and  the 
ease  with  which  it  is  torn  off  is  a  strong  argument  against  its  func- 
tion as  a  ligament. 

Summary  of  Functions.  In  conclusion,  I  think  I  can  safely 
say— 

1.  The  teres  does  not  prevent  dislocations,  since  it  is  possible  to 
tear  it  from  the  head  without  completely  dislocating  the  head. 

2.  The  ease  with  which  the  teres  can  be  torn  after  division  of  the 
capsule  is  also  proof  that  its  function  is  not  that  of  a  ligament. 

3.  While  it  is  true  that  the  teres  may  be  torn  without  a  dislocation 
taking  place,  it  is  also  true  that  without  rupturing  it  a  complete  dis- 
location is  possible. 

4.  If  the  teres  escapes  rupture  in  the  process  of  dislocation,  it  is 
highly  probable  that  it  will  be  ruptured  during  efforts  at  replacement, 
if  circumduction  be  employed. 

5.  As  there  is  no  evidence  that  the  teres  contributes  to  the  normal 
security  of  the  joint,  therefore  insecurity  or  weakness  of  the  articu- 
lation after  the  reduction  of  a  dislocation  cannot  logically  be  attrib- 
uted to  its  loss ;  nor  can  its  absence  be  said  to  favor  subsequent 
dislocations. 

6.  After  reduction,  no  unusual  position  of  the  limb  or  foot  (such 
as  flexion,  inversion,  or  abnormal  eversion)  can  justly  be  attributed 
to  the  lost  function  of  the  teres. 

Query.     Does  the  teres  ever  reunite  after  dislocation  ? 

From  an  anatomical  standpoint,  I  would  not  deny  the  possibility. 
The  probability  is  slight  when  we  think  that  coaptation  of  the  torn 
surfaces  may  be  wholly  or  partially  prevented  by  blood,  muscular 
debris,  shreds  of  torn  tendon.  Pathology  alone  can  enlighten  us  on 
this  point. 

THE  CAPSULE. 

No  single  structure  about  the  hip-joint  stands  second  in  importance 
to  the  capsule.  After  dislocation,  the  remnant  of  untorn  capsule,  as 
a  short  halter,  contributes  to  the  awkward  constraint  of  the  femur 


THE  CAPSULE.  13 

and  can  be  made  available  as  an  important  diagnostic  agent;  it  may 
also  constitute  a  principal  factor  in  accomplishing  reductions. 

The  capsule  cannot  be  studied  too  carefully.  It  is  a  strong  mem- 
brane, and  extends  like  a  sleeve  or  cuff  from  the  rim  of  the  socket 
to  the  base  of  the  neck  of  the  femur.     Its  functions  are : 

1.  To  check  the  movements  of  the  femur  against  a  tendency  to 
transcend  the  limits  of  safety.  If  one  will  dissect  every  structure 
from  the  joint  but  the  capsule,  he  will  be  surprised  at  the  resistance 
this  single  structure  will  offer  to  displacement. 

2.  To  offer  a  large  surface  for  the  attachment  of  muscles  that 
contribute  toward  the  safety  of  the  joint  and  preside  over  the  move- 
ments of  locomotion. 

3.  To  furnish  a  large  surface  for  the  display  of  synovial  membrane. 

4.  To  form  a  shut  sac  for  the  retention  and  distribution  of  synovia. 
The  pelvic  origin  of  the  capsule  is  from  the  bony  margin  of  the 

socket,  except  where  the  margin  is  deficient,  and  here  the  attachment 
is  to  the  transverse  ligament. 

The  femoral  attachment  is  to  the  base  of  the  neck — anatomists  say 
that  the  attachment  is  to  the  base  of  the  neck  anteriorly  and  to  the 
middle  of  the  neck  posteriorly.  I  will  explain  this  attachment  fur- 
ther when  speaking  of  the  ischio-femoral  ligaments.  Certain  parts 
of  the  capsule  are  worthy  of  special  study  in  connection  with  our  sub- 
ject.   Prominent  among  these  is  the  ilio-femoral  ligament.  (Fig.  10.) 

The  Ilio-femoral  Ligament.  This  is  not  a  distinct  ligament,  but 
only  a  remarkable  thickening  of  the  capsule  anteriorly.  Its  pelvic 
origin  is  below  the  anterior  inferior  spine  of  the  ilium.  At  this  point 
it  is  thicker  than  the  tendo-Achillis  (Weber).  From  this  point  it 
passes  down  to  be  attached  to  the  anterior  inter-trochanteric  line. 
In  its  passage  to  the  femur  it  does  not  continue  of  uniform  thick- 
ness, but  its  fibres  are  divided  into  two  columns  or  branches,  leaving 
a  space  between  them  where  the  membrane  is  thin  and  translucent.^ 
As  this  is  a  very  important  part  of  the  capsule,  with  a  long  and 
unwieldy  name,  Bigelow  has  christened  it  the  Y-ligament ;  and  this 
name  has  been  widely  accepted  by  teachers.  I  have  repeatedly  dis- 
sected it ;  and  while  the  branches  are  not  always  equally  distinct,  I 
feel  that  I  can  unqualifiedly  support  the  distinguished  surgeon  in 
what  he  claims  for  it.     The  two  branches  are  called  by  him  the  outer 

1  See  tn/ra— Strength  of  the  Capsule,  p.  17. 


14 


INTR OD  UCTOR  Y  STUD  Y. 


and  inner  branches  ;  and  he  attributes  special  functions  to  each.^  I 
shall  not  confine  myself  to  this  name  in  these  pages ;  for  experimental 
work,  supported  bv  pathology,  proves  that  much  more  than  the 
Y-ligament  is,  as  a  rule,  uninjured  in  dislocations ;  and  it  is  a  fact 
clearly  susceptible  of  demonstration  that  the  less  the  capsule  is  torn 


the  more  restraint  will  be  exercised  upon  the  dislocated  limb,  the 
nearer  the  head  will  lie  to  the  socket,  and  usually  the  facility  with 
which  reduction  can  be  accomplished  will  be  correspondingly  greater. 
Puho-  or  Pectineo-femoral  Ligament.  Continuous  with  the  ilio- 
femoral ligament,  but  further  inward,  is  one  known  as  the  pubo-  or 
pectineo-femoral  ligament.  This  structure  arises  from  the  pectineal 
line  as  far  inward  as  the  spine  of  the  pubes  ;  the  fibres  pass  outward 
to  blend  with  the  capsule.  It  presents  a  slightly  prominent  sickle- 
shaped  border,  which  extends  from  the  spine  of  the  pubic  bone  to 
the  femur  just  above  the  lesser  trochanter.     These  fibres  lie  beneath 


•  The  two  branches  of  the  Y  are  beautifully  brought  out  by  first  dislocating  the  femur  and 
then  looking  toward  the  light  from  the  inner  surface  ot  the  capsule.  This  will  prove  to  any 
one  that  the  branching  is  not  the  work  of  a  scalpel. 


THE  CAPSULE. 


15 


the  pectineus  muscle  and  the  sheath  of  the  femoral  vessels.  The 
fibres  are  made  tense  during  abduction.  When  I  have  dislocated 
the  head  inward  —  by  hyper-abduction — this  ligament  has  often 
escaped  injury,  the  head  making  its  escape  from  the  socket  beneath 


Fig.  11. 


Dislocation  inward— the  head  lying  in  the  thyroid  depression  and  partly  covered 
by  the  pubo-femoral  ligament. 

it.  At  other  times  it  has  been  torn.  It  is  torn  in  all  attempts  to 
convert  by  rotation  outward  a  direct  inward  dislocation  into  a  sub- 
spinous variety.  It  probably  always  escapes  when  the  head  is 
dislocated  downward  and  outward.  It  may  constitute  an  obstacle  to 
reduction. 

IscMo-femoral  Ligament.  This  accessory  band  is  called  by  Gray 
the  ischio-capsular  ligament,  but  I  think  incorrectly.  No  two 
anatomists  describe  it  alike ;  I  Avill  therefore  describe  it  as  I  have 
found  it.  It  arises  from  the  ischial  portion  of  the  rim  of  the  socket 
and  sends  its  fibres  to  the  capsule  to  be  blended  with  them.  As  its 
fibres  extend  upward  they  separate  like  two  fingers  or  terminal  pro- 
cesses, the  one  extending  forward  to  the  base  of  the  oblique  line,  the 
other  running  backward  to  the  digital  fossa.     Between  these  pro- 


16 


INTBOD  UCTOR  Y  STUD  Y. 


cesses  is  a  web,  like  the  web  between  the  fingers  of  the  hand,  with 
a  distinct  border  and  entirely  free  from  attachment  to  the  neck. 
Anatomists  say  that  the  capsule  attaches  to  the  neck  posteriorly 
midway  in  its  length.  Now,  it  is  true  that  above  the  web  (Fig.  12) 
there  is  no  capsule,  and  that  the  synovial  membrane  reaches  only 
half-way  the  length  of  the  neck  posteriorly ;  but  there  is  a  function 


Fig.  12. 


of  the  capsule  that  would  be  lost  if  the  capsule  attached  directly  to 
the  neck  midway  of  its  length  ;  and  that  function  is  strength.  Were 
the  fibres  lost  in  the  capsule,  as  described  by  some  anatomists,  they 
would  confer  no  strength  or  barrier  against  dislocation.  To  gain 
strength  they  must  pass  from  bone  to  bone,  from  the  rim  of  the 
socket  to  the  base  of  the  neck.     I  have  spoken  of  the  web  as  having 


STRENGTH  OF  THE  CAPSULE.  17 

a  free  distinct  border,  and  have  said  that  this  web  does  not  attach 
to  the  neck.  I  mean  by  this  that  it  is  not  attached  as  a  ligament. 
It  is  loosely  attached  by  a  reflection  of  synovial  membrane  and  by 
connective  tissue;  but  its  only  function  in  the  attachment  is  to 
retain  synovia.  The  absence  of  capsular  attachment  in  the  middle 
of  the  neck  posteriorly  does  not  weaken  the  joint,  for  any  stress  will 
take  the  direction  of  one  or  the  other  of  these  processes,  or  of  both. 

Strength  of  the  Capsule. 

The  crowbar  is  so  constructed  that  its  o-reatest  strength  shall  be 
at  the  point  of  greatest  strain,  i.  e.,  a  point  over  the  fulcrum,  and 
the  further  we  go  from  this  point  the  less  material  do  we  find  in  the 
bar.  Now  the  capsule  is  constructed  on  this  plan :  it  is  thickest 
where  the  strain  is  necessarily  the  greatest,  and  that  is  near  the  rim 
of  the  socket.  In  every  strain  upon  the  capsule  the  pressure  must 
be  exerted  through  the  head  of  the  femur  and  proceed  from  within 
the  capsule  and  extend  outward.     The  capsule  may  be  cut  with  a 

Fig.  13. 


bistoury  from  without  inward,  but  it  must  be  burst  from  within  out- 
ward. In  every  position  in  which  the  femur  may  be  placed,  if  the 
head  is  thereby  brought  against  the  capsule,  it  will  be  brought 
against  that  part  which  is  nearest  to  the  pelvic  attachment,  and 
hence  everywhere  the  pelvic  extremity  of  the  capsule  is  thicker, 
stronger,  and  more  even  in  construction  than  the  femoral  extremity. 
When  we  examine  the  femoral  extremity  of  the  capsule  we  find  that 
the  ilio-femoral  band  splits  and  separates,  making  two  attachments. 
We  see  the  pectineo-femoral  making  a  single  femoral  insertion  ;  we 

2 


1 8  INTBOD  UCTOB Y  STUB  Y. 

find  the  ischio-femoral — one  at  its  pelvic  origin — dividing  into  two 
branches  at  the  femoral ;  and  the  question  arises,  What  does  it  all 
mean  ?  The  answer  is  close  at  hand.  The  femur  being  a  crooked 
bone,  enjoying  universal  motion,  with  capsular  fibres  of  unequal 
length,  could  not  find  a  use  for  all  the  fibres  were  they  inserted  of 
equal  thickness  into  the  neck.  Not  only  is  this  true,  but,  were  the 
capsule  of  equal  thickness  at  its  femoral  attachment,  the  directions  of 
strain  would  be  interfered  with,  since  some  parts  of  the  capsule  by 
its  unwieldy  thickness  would  be  in  the  way  of  others.  So  far  from 
the  gap  between  the  legs  of  the  Y-ligament  being  a  cunning  device 
of  a  scalpel  in  the  hands  of  Prof.  Bigelow  (as  I  have  heard  declared), 
this  gap  is  rather  the  conservation  of  material,  being  thin  here, 
with  no  other  function  than  to  retain  synovia,  while  the  branches 
themselves  of  the  Y  are  rather  the  expressions  of  normal  hyper- 
trophy due  to  healthful  physiological  activities.  As  in  the  case  of 
the  mast  of  a  ship,  the  strain  may  fall  first  on  one  rope,  then  on 
another,  and  lastly  on  both  together ;  so  the  strain  on  the  femoral 
attachment  of  the  ilio-femoral  ligament  falls,  in  the  ordinary  func- 
tions of  locomotion,  first  on  one  branch,  then  on  the  other,  or  upon 
both  together.  In  circumduction  the  strain  would  pass  around  the 
base  of  the  joint,  starting,  it  may  be,  at  the  outer  branch,  extending 
then  to  both,  then  to  the  inner,  on  to  the  pubo-femoral,  and  still  on 
to  the  ischio-femoral.  Thus  we  can  see  that  each  end  of  the  capsule 
has  a  distinct  function.  At  the  pelvic,  where  the  head  of  the  femur 
comes  in  direct  contact  with  it,  it  is  thick  and  strong,  with  no  points 
of  attenuation  that  would  easily  permit  the  head  to  slip  through ;  at 
the  femoral  attachment,  the  part  unapproached  by  the  head,  the 
material  is  gathered  up  in  bundles  that  take  the  direction  of  greatest 
strain.  Thus  is  solved  the  problem  of  maximum  strength  with 
minimum  amount  of  material ;  and  the  crucial  test,  that  the  femoral 
attachment  is  as  strong  as  the  pelvic,  is  found  in  the  frequency 
with  which  dislocations  are  reduced — were  the  capsule  uniformly 
torn  from  its  femoral  attachment,  restorations  would  be  the  excep- 
tion. 

The  Femoral  Vessels. 

The  femoral  vessels  are  very  rarely  injured  in  dislocations.  Their 
immunity  is  due  (1)  to  their  anatomical  relations  to  the  joint;  (2)  to 
the  muscles  that  lift  them  out  of  tlie  reach  of  danger  at  the  instant 


THE  FEMORAL  VESSELS. 


19 


dislocation  takes  place ;  and  (3)  to  the  relation  of  the  femui'  to  the 
vessels  in  the  act  of  dislocation.^ 

At  their  exit  from  the  pelvis  beneath  Poupart's  ligament  the 
femoral  vessels  lie  on  a  plane  a  little  anterior  to  the  head  of  the 
femur.     They  are  not  covered  with  muscles  in  Scarpa's  triangle,  but 


Fig.  14. 


lie  upon  muscles  "which  pass  from  the  pelvis  to  the  linea  aspera. 
The  head  of  the  femur  approaches  the  femoral  vessels  only  in  dis- 
locations inward  ;  and  in  dislocations  inward  the  femur  must  be 
flexed  and  abducted  the  instant  the  rupture  of  the  capsule  takes 
place.     Hence  the  muscles  that  constitute  the  floor  of  the  femoral 


'  In  the  only  case  that  I  have  seen  reported  of  fatal  hemorrhage  the  femoral  vessels  were 
ruptured  by  hyper-extension  of  the  thigh  upon  the  pelvis.  In  this  position  the  vessels  are 
drawn  tensely  across  the  head  of  the  femur  at  the  instant  when  the  head  bursts  through  the 
capsule.  lu  the  case  reported  a  cavalryman  was  thrown  from  his  horse  and  the  whole 
thigh  carried  backward,  so  that  the  knee  lay  between  the  shoulders.  Stimson's  Treatise  on 
Dislocations. 


20 


INTR  OD  UCTOR  Y  ST  UD  Y. 


vessels  are  more  or  less  tense,  and  lift  them  out  of  the  way.  In  the 
accompanying  figure  (Fig.  14)  1  have  represented  only  a  single 
muscle — the  pectineus. 

If  the  head  be  dislocated  inward,  it  will  pass  below  the  femoral 
vessels  and  leave  them  and  their  sheaths  wholly  undisturbed.  If 
the  limb  is  now  permitted  to  descend  by  its  own  weight,  the  femoral 
vessels  will  be  found  lying  across  the  head  or  neck,  the  head  being 
internal  to  the  vessels.^    (Fig.  15.)     1  believe  this  to  be  the  usual — 


Fig.  15. 


Double  dislocation  of  the  femur  inward.    (Dissecting-room  reproduction.) 

not  the  occasional — relation  of  the  head  to  the  vessels  in  dislocations 
inward.  I  doubt  very  much  that  the  head  is  ever  dislocated  directly 
upward  and  to  the  outer  side  of  the  vessels.  The  head  can,  however, 
reach  the  outer  side  of  the  vessels  by  first  being  dislocated  inward 
and  then  shifting  its  position  beneath  and  to  the  outer  side  of  them. 
Fig.  15  suggests  the  easy  compression  of  the  femoral  vessels  in  a 
thyroid  dislocation. 

The  Fascia  Lata. 

This  structure  is  not  concerned  to  any  material  degree  in  the 
subject  of  dislocations  of  the  hip,  and  yet  a  knowledge  of  its  normal 


'  Sir  Astley  Cooper  (Fractures  and  Dislocations)  says:  "  Upon  examining  the  seat  of  injury 
it  was  found  that  the  head  of  the  femur  had  been  thrown  to  the  inner  side  of  the  femoral 
vessels;  "  and  in  a  case  reported  by  James  Douglas  (Monthly  Journal  of  Medical  Sciences, 
1843),  it  is  stated  that  the  head  "  lay  internal  to  the  bloodvessels,  having  passed  beneath 
them."  Mr.  Douglas  cites  this  as  an  instance  of  the  great  force  that  was  necessary  to  produce 
such  an  injury.  This  prevailing  opinion  that  the  head  was  dislocated  directly  upward  and 
inward,  external  to  the  vessels,  was  due  to  the  widespread  influence  of  the  eminent  British 
surgeon,  who  never  thought  that  an  easier  mechanism  of  dislocations  was  possible.  Had  he 
done  so,  he  would  ])robably  have  thought  of  an  easier  mode  of  reduction. 


THE  FASCIA  LATA, 


21 


relations  may  be  of  much  diagnostic  value  in  certain  pathological 
conditions,  such  as  fracture  of  the  neck  of  the  femur  and  hip-joint 
disease — injuries  that  have  been  mistaken  for  dislocations.  I  shall 
not  enter  fully  into  its  anatomical  relations,  but  merely  touch  upon 
parts  that  illustrate  important  conditions. 

The  chief  function  of  this  fascia  is  in  the  erect  posture,  as  in 
standing  at  rest,  walking,  and  running ;  hence  it  enjoys  to  a  remark- 
able degree  the  double  function  of 
muscle  and  tendon.  That  part  of 
the  fascia  which  especially  concerns 
us  may  be  said  to  arise  from  the 
crest  of  the  ilium.  From  this  cres- 
centic  bony  origin  the  fascia,  though 
it  extends  around  the  entire  limb,  for 
'Our  present  purpose  may  be  said  to 
converge  to  a  narrow  band,  and  finally 
to  be  inserted  into  the  outer  tuber- 
osity of  the  tibia.  (Fig.  16.)  A 
threefold  function  of  this  important 
structure  consists  in  its  acting  as  a 
tensor  to  fascise  that  sheathe  the 
muscles  of  the  thigh,  in  acting  as  a 
constant  check  to  a  tendency  to  dis- 
placements, and  in  operating  as  an 
important  agent  in  supporting  the 
body  at  rest — thus  relieving  the  over- 
taxed muscles. 

1.  As  a  Tensor  of  the  Fascia, 
This  is  chiefly  accomplished  by  the 
tensor  vaginae  femoris  and  the  pos- 
terior half  of  the  gluteus  maximus. 
Neither  of  these  has  a  direct  bony 
attachment,    but    both    are    inserted 

into  this  broad,  dense,  powerful  fascia.  In  running  and  walking  these 
muscles  make  tense  this  fascia.  Their  action  can  be  studied  with 
great  ease  as  one  ascends  a  flight  of  stairs,  by  holding  the  finger 
against  the  tendon  of  the  fascia  just  above  the  outer  condyle  of  the 
knee. 

2.  As  a  Chech  to  a  Tendency  to  Displacement.    With  every  step 


22  INTROD  UCTOR  Y  STUD  Y. 

there  is  a  tendency  to  displacement.  Under  the  ordinary  motions 
of  the  hip  the  head  of  the  femur  is  not  retained  in  the  socket  by 
arbitrary  ligaments.  The  function  of  a  ligament  is  to  bind  ;  but  the 
hip  has  the  freest  motion  in  all  directions.  Hence  an  accommoda- 
tive pressure,  supplementary  to  atmospheric  pressure,  constant  but 
yielding,  suiting  itself  to  the  varied  changes  that  take  place,  is 
required.  This  is  accomplished  in  part  by  muscles  that  are  inserted 
directly  into  the  capsule.  But  there  is  another  entirely  independent 
and  most  important  agency,  hitherto  possibly  unnoticed,  reserved  for 
the  fascia  lata.  This  fascia,  under  the  control  of  the  tensor  vaginae 
femoris  and  gluteus  maximus,  passes  directly  over  the  great  trochan- 
ter, exerting  direct  active  pressure  upon  it.  The  fascia  lata  does  not 
have  an  attachment  to  the  great  trochanter.  If  it  did,  the  femur 
could  not  be  flexed  upon  the  abdomen.  As  it  is,  the  trochanter 
moves  with  every  step  beneath  the  fascia — to  which  action  is  prob- 
ably due  the  large  bursa  always  found  beneath  it.  The  first  upper 
attachment  that  the  fascia  makes  to  the  shaft  is  through  the  tendon 
of  the  gluteus  maximus,  and  from  this  point  down  it  is  attached  to 
the  linea  aspera  the  whole  length  of  the  bone.  As  proof  that  the 
fascia  exerts  pressure  upon  the  head  through  the  trochanter  I  adduce 
the  following  personal  experience  :  In  December,  1884,  I  was  seized 
with  a  pain  in  the  outer  aspect  of  my  right  thigh  which  soon  devel- 
oped into  an  abscess  beneath  the  fascia  lata.  In  order  to  facilitate 
drainage,  I  requested  Dr.  D.  Hayes  Agnew  to  cut  the  fibres  of  the 
fascia  transversely.  This  he  did  ;  and,  on  my  recovery  after  nine 
weeks  of  recumbency,  I  was  not  a  little  surprised  at  the  inse- 
curity of  the  head  of  the  femur,  which  became  partially  dislocated 
with  each  step  and  returned  with  a  decided  jar  and  an  audible  sound. 
This  could  not  have  been  due  to  anything  but  the  division  of  the 
fascia  lata  and  its  consequent  lengthening  and  changed  relations, 
which  withdrew  the  normal  pressure  from  the  trochanter ;  thus  a 
joint  that  had  never  exhibited  the  slightest  disease  or  tendency  to 
insecurity  before  the  division  of  the  fascia,  became  subsequently, 
upon  my  first  use  of  it,  so  unstable  that  I  feared  for  a  time  that  a 
synovitis  would  ensue  from  the  constant  concussions  occasioned  by 
even  the  gentlest  use.  By  degrees  the  tensor  muscles  shortened  and 
re-established  their  former  control ;  but  the  security  has  never  fully 
returned. 

A  further  confirmation  of  the  statement  that  the  fascia,  under  the 


THE  FASCIA  LATA.  23 

control  of  the  tensor  muscles,  makes  pressure  upon  the  head  through 
the  great  trochanter  is  seen  in  the  early  symptom  of  abduction  in 
hip-disease.  Adduction — the  reverse  of  abduction — makes  tense 
the  fascia  and  drives  the  head  into  the  socket.  In  erect  walking, 
the  fascia  makes  no  pressure  on  the  trochanter  in  its  office  as  a  ten- 
don, but  it  does  make  pressure  through  the  tensor  muscles.  There- 
fore, in  hip-joint  disease  the  patient,  to  escape  pressure  from  both 
sources,  abducts  the  thio;h  and  adds  flexion  to  abduction  to  relax 
still  further  the  psoas,  the  tendon  of  which  passes  directly  over  the 
head  of  the  femur.  The  theory  which  is  far  too  widely  spread, 
that  lengthening  exists  in  the  early  stage  of  hip-joint  disease,  and 
is  due  to  effusion  in  the  joint,  thus  forcing  the  head  out,  cannot 
be  sustained.  There  is  no  lengthening ;  the  apparent  lengthening 
is  due  to  asymmetry.  Place  both  limbs  in  equal  degree  of  flexion 
and  abduction  (see  Fig.  88),  and  the  apparent  lengthening  will  dis- 
appear. 

3.  As  a  Support  for  the  Body  at  Rest.  Man  in  the  erect  posture 
finds  himself  shiftino;  his  weight  from  one  limb  to  the  other.  This 
function  of  standing  at  rest  has  been  attributed  to  the  agency  of  the 
capsule  and  the  ligamentum  teres.  This  is  true  only  to  a  very 
moderate  degree,  the  chief  agency  being  the  strong,  flexible,  but 
inelastic  band  of  fascia  that  passes  from  the  crest  of  the  ilium  to 
the  outer  tuberosity  of  the  tibia.  (Fig.  17.)  This  tendon  is  not 
tense  as  a  ligament  in  the  erect  posture,  i.  e.,  when  one  is  standing 
equally  upon  both  feet.  When  under  such  circumstances  it  is  tense, 
this  tension  is  voluntary  and  due  to  the  action  of  the  tensor  muscles. 
Were  the  fascia  tense  in  the  erect  posture,  further  adduction  (so 
important  at  times  to  preserve  one's  balance)  would  be  impossible. 
In  standing  at  rest,  man  always  throws  his  full  weight  upon  one 
limb,  and  the  relation  of  this  limb  to  the  pelvis  is  that  of  adduction. 
Adduction  makes  tense  the'  fascia,  because  it  makes  prominent  the 
trochanter,  which,  as  it  were,  presses  outward  against  it.  In  stand- 
ing at  rest,  man  tilts  the  pelvis  toward  the  limb  on  which  he  stands 
until  it  is  finally  arrested,  the  body  balanced,  and  the  muscles 
rested.^ 

Hammock  Function.  While  the  more  important  functions  of 
this  fascia  are  exhibited  in  the  erect  posture,  it  enjoys  a  function  in 

1  I  have  been  told  that  flamingoes  sleep  standing  on  one  leg,  and  that  one  can  tell  which 
of  the  flock  is  sentinel  by  noting  which  bird  Is  standing  on  both  legs. 


24 


INTRODUCTORY  STUDY. 


the  horizontal  position  worthy  of  our  consideration.  This  I  shall 
denominate  the  hammock  function.  In  dorsal  recumbency  the  toes 
turn  outward.  Why  do  they  do  so  ?  It  is  not  due  to  muscular 
action,  for  it  persists  in  sleep  and  is  present  in  the  paralytic.  It  is 
due  solely  to  the  weight  of  the  limb,  which  rotates  outward  on  the 
neck  of  the  femur.  It  is  simply  an  expression  of  external  rotation, 
the  motor  being  gravity,  and  the  radius  of  action  being  the  neck  of 
the  femur.  But  why  does  the  rotation  stop  at  the  same  j^/'ccise  limit 
each  time  ?  Let  a  person  stand  erect,  and,  making  a  pivot  of  his 
heels,  rotate  both  limbs  quickly  outward.  They  both  stop  suddenly 
and  at  the  same  precise  point  each  time,  no  matter  how  often  or 
powerfully  the  motion  is  repeated.  Why  ?  Because  they  are  checked 
by  a  ligament.  This  check  is  through  the  fascia  lata,  which  supports 
the  limb  as  in  a  hammock.  This  support  is  of  great  value  after  the 
reduction  of  a  dislocation.     When  the  surgeon  in  such  a  case  ties 


Fig.  17. 


the  ankles  together  he  is  practically  adducting  both  limbs,  and  this 
compels  the  fascia  lata  to  make  pressure  upon  the  trochanter.  Thus 
a  force,  held  in  reserve  and  entirely  unharmed  by  the  traumatism  of 
dislocation,  is  made  of  great  service  during  repair.  Further  proof 
that  this  fascia  influences  rotation  can  be  elicited  in  the  following 
manner.  Place  a  person  on  his  back,  with  his  heels  touching  each 
other,  and  note  the  degree  of  external  rotation.  Now,  while  the 
patient  is  perfectly  passive,  let  the  surgeon  abduct  both  the  patient's 
limbs.  As  the  abduction  increases — the  knees  being  kept  stiff — the 
external  rotation  will  increase,  because  the  limbs  are  passing  from 
under  the  control  of  the  fascia.  Now  let  the  surgeon  approximate 
the  patient's  feet.  As  he  does  so,  the  normal  degree  of  rotation  will 
be  resumed.  In  this  manoeuvre  the  patient  has  been  perfectly  pas- 
sive, and  the  change  in  rotation  uninfluenced  by  muscular  action. 


THE  FASCIA  LATA. 


25 


The  same  effect  may  be  produced  upon  the  cadaver.  It  is  this  auto- 
matic mechanical  control  of  the  thigh  which  brings  it  down  with  such 
a  precise  degree  of  external  rotation  that  makes  it  possible  for  man 
to  run  at  a  high  rate  of  speed  without  danger  of  tripping  or  bringing 
the  foot  down  insecurely. 

On  page  29  I  have  noted  the  reasons  why  it  is  impossible  to  flex 
the  femur  on  the  pelvis  without  first  flexing  the  leg  on  the  thigh. 
At  this  point  I  wish  to  say  that,  even  with  the  leg  flexed  on  the 
thigh  and  the  ilio-tibial  band  thoroughly  relaxed,  hyper-flexion  of  the 


Fig.  is. 


femur  makes  tense  the  upper  fibres  of  the  fascia  that  give  support  to 
the  head  in  this  position  and  tend  to  check  a  tendency  to  displace- 
ments. Fig.  18  indicates  also  how  possible  it  is  for  the  head  to 
wound  or  even  transfix  the  gluteus  maximus  (p.  65,  Case  IV.)  when 
dislocation  takes  place  during  flexion,  adduction,  and  inward  rotation 
of  the  femur. 

A  matter  of  great  practical  value  is  to  note  the  deportment  of 
this  fascia  after  fracture  of  the  neck  of  the  femur.  All  that  I  have 
said  about  the  fascia  lata  in  regard  to  support  depends  upon  an 
unbroken  femur.  Let  the  femur  be  broken  at  any  point  in  its  con- 
tinuity between  the  head  and  the  condyles,  and  it  is  plain  that  it  can 


26 


INTRODUCTORY  STUDY. 


no  longer  make  tense  this  fascia.  Now,  fracture  in  the  shaft  of  the 
femur  is  easy  of  detection.  Not  so  with  fracture  of  the  neck  of  the 
femur,  and  this  is  specially  important,  as  its  frequency  increases  with 
adv^ancing  years,  rendering  an  easy  means  of  diagnosis  of  inestimable 
importance.  To  avail  one's  self  of  this  principle,  it  is  necessary  to 
note  that  the  fascia  during  adduction  is  tense  (Fig.  20)  and  can  be 
felt  as  a  firm  resistinor  band  between  the  trochanter  and  the  crest  of 


Fig.  19. 


^^.-T- 


:^^ 


Abduction  of  both  femurs.    The  arrows  point  to  regions  where  the  fascia  lata  will  be 
notably  relaxed. 

the  ilium,  and  like  a  firm  round  cord,  about  the  size  of  the  little 
finger,  near  the  knee,  above  the  outer  condyle.  The  examiner  can 
first  take  the  sound  limb,  and,  adducting  it,  bring  into  prominence  the 
tendon,  best  felt  above  the  outer  condyle.  He  can  then  take  the 
suspected  limb,  and,  gently  adducting  it,  feel  the  resistance.  If  the 
resisting  band  or  cord  be  present  in  equal  degree  upon  both  sides, 
there  is  strong  presumptive  evidence  of  a  sound  femur.  If  it  be 
absent,  this,  with  the  corroborative  testimony  that  attends  an  acci- 
dent, should  have  great  consideration. 


THE  FASCIA  LATA. 


27 


Brief  Resume  of  the  Functions  of  the  Fascia  Lata.  1 .  It 
forms  the  sheath  or  envelope  of  the  most  important  walking  muscles 
of  the  thigh ;  during  progression  the  tension  of  this  fascia  (through 
the  gluteus  maximus  and  tensor  vaginae  femoris)  is  of  the  utmost 
advantage;  through  the  same  muscles  it  steadies  the  head  of  the 
femur  in  the  socket. 

Fig.  20. 


2.  It  checks  adduction  of  the  extended  thigh  through  the  ilio- 
tibial  band. 

3.  It  checks  outward  rotation  of  the  extended  thigh. 

4.  It  assists  the  hamstring  muscles  and  the  sciatic  nerve  in  check- 
ing flexion  of  the  extended  limb. 

5.  It  checks  a  tendency  to  hyper-flexion  of  the  thigh  upon  the 
abdomen. 

6.  It  contributes  largely  to  man's  ability  to  stand  at  rest. 


28  I^TR OD  UCTOR  Y  STUD  Y. 

7.  After  the  reduction  of  a  dislocation  at  the  hip-joint  the  fascia 
lata  and  the  untorn  portion  of  the  capsule  are  our  main  reliance  in 
retaining  the  head  of  the  femur  in  place.  If  the  feet  are  tied 
together,  the  fascia  and  nothing  else  presses  the  head  into  the  socket. 

8.  After  fracture  of  the  neck  this  ilio-tibial  band  is  relaxed  during 
adduction. 

9.  As  adduction  tightens  the  ilio-tibial  band,  and  abduction  re- 
laxes it,  the  latter  position  is  voluntarily  assumed  in  the  early  stage 
of  hip-disease. 

10.  As  flexion  of  the  extended  limb  tightens  the  fascia  lata  and 
drives  the  head  into  the  socket,  this  manoeuvre  elicits  pain  in  the 
early  stage  of  hip  disease. 


THE  SCIATIC  NERVE  AND  HAMSTRING  MUSCLES. 

The  sciatic  nerve  makes  its  exit  from  the  pelvis  at  the  lower 
border  of  the  pyriformis  muscle  (Fig.  21)  and  proceeds  in  a  direct 
line  to  the  popliteal  space.  It  passes  between  the  great  trochanter 
and  the  tuberosity  of  the  ischium,  but  its  relation  to  the  stable  pelvis 
is  closer  and  more  intimate  than  to  the  movable  trochanter.  The 
latter  can  be  rotated  from  or  toward  the  nerve,  but  cannot  pinch  it. 
It  is  covered  by  the  thick,  warm,  fleshy  gluteus  maximus  and  the 
hamstring  muscles,  and  is  thus  protected  against  sudden  changes  in 
temperature. 

Since  dislocations  occur  and  are  reduced  with  the  femur  in  the 
flexed  position,  I  shall  present  the  nerve  in  its  relation  to  the  socket 
and  muscles  in  this  position.  In  the  accompanying  diagram  the 
nerve  is  seen  emerging  from  the  great  sciatic  foramen,  in  the  inter- 
space between  the  pyriformis  and  the  obturator  internus,  then  cross- 
ing the  quadratus  femoris,  and  lying  upon  it  and  the  adductor  magnus 
until  it  reaches  the  popliteal  space,  where  it  gives  off  a  large  branch. 
The  nerve  is  attached  loosely  to  the  muscles  that  surround  it,  but  its 
special  guardian  is  the  outer  hamstring  muscle,  the  biceps.  The 
nerve  passes  below  the  socket  until  it  reaches  the  tendon  of  the  biceps, 
to  which  it  becomes  quite  intimately  attached.  In  adduction,  abduc- 
tion, and  the  various  movements  of  the  thigh,  the  nerve  follows  the 
muscle. 

As  the  nerve  is  large  and  practically  incapable  of  being  stretched, 


THE  SCIATIC  NERVE  AND  HAMSTRING  MUSCLES. 


29 


it  is  interesting  to  notice  how  Nature,  in  the  movements  of  the  limb, 
has  phmned  to  throw  the  brunt  of  many  an  injury  upon  other  and  less 
important  structures.  The  structures  that  are  made  tense  by  any 
attempt  to  flex  the  pelvis  on  the  extended  thigh  and  leg — or,  what  is 
the  same  thing,  to  flex  the  extended  limb — are :  the  fascia  lata,  the 
hamstring  muscles,  and  the  sciatic  nerve.  I  will  describe  only  the 
action  of  the  hamstring  muscles,  since  the  mechanism  is  practically  the 
same  in  all.    In  Fig.  22  (p.  30)  the  femur  and  the  hamstring  muscles 


Fig.  21. 


are  represented  as  parallel  and  of  equal  length.  [Note  in  the  dia- 
gram that  the  origin  of  the  muscle  {B)  is  below  and  to  the  right  of 
the  socket  and  that  the  insertion  (Z>)  is  below  and  to  the  right  of  the 
knee-joint.]  If,  now,  we  flex  the  femur  to  a  right  angle,  the  con- 
dyles will  reach  as  high  as  E^  while  the  muscle,  though  it  be 
equally  long,  will  reach  only  to  F.  If  an  attempt  were  made  to 
raise  the  tibia  to  the  perpendicular,  F  must  rise  as  high  as  Cr.  It 
must  be  plain,  therefore,  that  flexing  the  leg  on  the  thigh,  in  walk- 


30 


INTRODUCTORY  STUDY. 


ing  or  running,  is  not  a  voluntary  or  muscular  action,  but  one  of 
pure  mechanics ;  for  the  instant  the  psoas  and  other  muscles  flex 


Fig.  22. 


e  ... 


m 


N.  T.  F.    Xeuro-tendinons  fascia  extending  between  the  sciatic  nerve  and  the  tendon, 
binding  both  together  and  normally  exercising  some  constraint  upon  the  nerve. 


THE  SCIATIC  NERVE  AND  HAMSTRING  MUSCLES. 


31 


the  thigh  on  the  pelvis  that  instant  the  leg  becomes  flexed  on  the 

thigh  through  the  unstretchable  fascia  lata  and  the  hamstring  mus- 
es o  o 

cles.  The  important  principle  to  which  I  would  call  attention  is, 
that  when  the  femur  is  flexed  at  right  angles  with  the  pelvis  the  leg 
must  he  flexed  to  relax  the  nerve  and  the  hamstring  muscles. 

I  have  already  said  that  the  nerve  follows  the  hamstring  muscles 
in  the  various  positions  of  the  femur,  as  in  abiuction,  adduction,  etc. 


Fig.  24. 


If  the  limb  be  abducted,  the  nerve  and  muscles  will  run  parallel  to  the 
shaft  of  the  femur.  (Fig.  23.)  Now,  if  the  femur  is  carried  still  further 
outward,  the  head  may  burst  through  the  capsule  and  be  dislodged 
inward.  (Fig.  24.)  In  such  a  case  it  is  plain  that  no  injury  will  accrue 
to  the  nerve.  But  suppose  the  head,  from  being  in  the  position  of  thy- 
roid luxation,  should  be  shifted  outward  to  that  of  a  dorsal  luxation, 
how  is  it  to  get  there  ?  Easily  enough,  but  not  Avithout  danger  to 
the  nerve,  since  there  is  but  one  possible  path  for  a  dislocation  inward 
to  take  in  order  to  become  a  dislocation  outward,  and  that  is,  be- 


32 


INTR OD  UCTOE  T  STUD  Y. 


tween  the  hamstring  tendon  and  the  socket.  Xow  the  tendon  of 
origin  of  these  muscles  is  within  half  an  inch  of  the  socket,  and  the 
nerve  is  nearer,  if  anything.  Under  no  circumstances  can  the  head 
he  circumducted  and  carried  outward  without  traumatism,  more  or 
less  severe,  to  the  nerve.  If  the  sweep  of  the  knee  through  which 
this  may  he  effected  be  a  large  one,  and  especially  if  there  he 
sufficient  extension  of  the  leg  on  the  thigh  to  shorten  and  make  tense 
the  nerve,  then  there  is  great  danger  that  the  head  will  pass  between 
the  nerve  and  the  tendon,  and  that  the  result  represented  in  the 
diagram  (Fig.  25)  will  take  place.     This  condition  was  present  in 


Fig.  25. 


Compare  Fig.  2-5  with  Fig.  Zi,  and  note  how  completely  the  nerve  may  be  torn  from  its 
surrounding  and  controlling  attachments  through  circumductive  movements  after  dis- 
location. 


Quain's  case  (Fig.  50),  and  can  be  readily  reproduced  experi- 
mentally. If  such  a  condition  be  suspected,  the  fact  may  be  ascer- 
tained by  having  an  assistant  push  upward  upon  the  knee  in  the 
direction  of  the  long  axis  of  the  shaft  of  the  femur,  while  the  surgeon, 
by  extending  and  flexing  the  leg,  will  find  the  nerve  made  alter- 
nately tense  and  relaxed  in  the  popliteal  space,  if  it  be  over  the  neck 
and  the  head  out  of  the  socket.  In  such  a  case  a  successful  reduction 
of  the  head  will  release  the  nerve,  but  the  traumatism  may  have  been 
80  severe  that  a  prolonged  neuritis,  a  partial  or  complete  paralysis, 
may  result.  Such  a  condition,  if  unrelieved  by  replacement,  would, 
of  course,  be  one  of  prolonged  suffering. 

If  the  head,  in  its  transit  from  within  outward,  pass  between  the 
nerve  and  the  socket,  the  former  may  be  bruised  a  little,  but  not 


THE  SCIATIC  NERVE  AND  HAMSTRING  MUSCLES. 


33 


detached  from  the   tendon,  and  will  lie,  after  dislocation,  between 
the  head  or  neck  and  the  tuberosity.     This,  taking  all  the  varieties 


Fig.  26. 


of  displacement  into  consideration,  is,  I  think,  the  most  frequent 
condition,  and  when  it  occurs  the  danger  of  hooking  up  the  nerve 
through  the  efforts    at    reduction  will  be  greatly  increased  if   the 


Fig    27. 


head  in  passing  outward  catches  up  the  nerve  and  tears  it  from  its 
attachments.     This  is  no  random  statement,     Bigelow,  Morris,  and 


34  INTBOD  UCTOR  Y  STUD  Y. 

Johnson  have  caught  it  up  in  experimental  work,  and  Koons  did  it 
in  actual  practice.^ 

If  the  nerve  be  hooked  up  during  the  reduction,  the  following 
conditions  will  be  present :  The  nerve  will  cross  the  front  of  the 
neck  and  lie  beneaih  the  untorn  parts  of  the  capsule  and  the  tendon 
of  the  psoas  muscle  (Fig.  27,  p.  33) ;  it  then  descends  through  the 
rent  in  the  muscular  partition  to  the  adductor  magnus,  beneath 
which  it  descends  to  the  popliteal  space.  At  least  three  inches  of 
the  nerve  are  taken  up  by  this  detour,  and  hence  the  thigh  must  be 
flexed  on  the  pelvis  and  the  leg  on  the  thigh  to  accommodate  them 
to  the  shortened  nerve. 

If  the  dislocation  occur  through  flexion,  adduction,  and  rotation 
inward,  the  capsule  may  yield  and  the  head  may  escape  outward 
and  downward  without  touching  the  pelvis  in  the  descent.  In  such 
cases  1  have  seen  the  head  fall  directly  upon  the  nerve,  from  which 
it  can  slip  to  either  side. 

Fig.  28.  Fig.  29. 


SCIATIC  '/V£/fV£  ■ 


I  have  already  spoken  of  the  guardianship  of  the  nerve — i.  e., 
how  the  nerve  is  protected  through  attachment  to  the  hamstring 
muscles,  and  how  it  follows  them  in  adduction  and  abduction.  (Fig. 
23.)  As  the  adductor  muscles  are  very  powerful,  it  is  highly  probable 
that  more  dislocations  occur  through  flexion,  adduction,  and  rotation 
inward  than  in  flexion,  abduction,  and  rotation  inward.  Not  that 
these  muscles  bave  any  direct  agency  in  producing  a  dislocation  or 
preventing  one,  but,  simply  by  their  power,  place  the  limbs  in  a 
state  of  adduction  at  the  instant  that  the  fatal  flexion  and  rotation 
inward  produce  the  displacement.  In  hyper-adduction  the  nerve 
skirts  the  border  of  the  socket  (Fig.  28),  and  the  head  may,  in  transit 

1  Reminiscences,  supra. 


TJTE  HAMSTRING  MUSCLES. 


35 


outward,  scarcely  touch  it.  In  hyper-ahduction  the  nerve  runs  parallel 
"with  the  shaft  (Fig.  29),  and  the  danger  to  it  then  from  dislocation 
outward  is  imminent  and  unavoidable.  Thus  we  have  two  positions 
in  which,  if  dislocations  take  place,  we  have  good  reasons  to  predict 
the  condition  of  the  nerve ;  and  hence  when  we  read  in  accounts  of 
autopsies  that  the  nerve  was  caught  up  over  the  neck — lacerated, 
slightly  bruised,  or  uninjured — we  have  a  warrant  for  placing  the 
limb  in  a  position  between  hyper-adduction  and  hyper-abduction  that 
will  best  fulfil  the  conditions. 

That  which  I  have  said  about  the  nerve  does  not  apply  to  the 
quadratus  muscle.  This  muscle  is  always  put  on  the  stretch  by 
flexion,  and  the  tension  is  increased  by  rotation  inward.  Hence, 
when  this  muscle  is  torn  in  two  with  some  of  the  fibres  of  the  adduc- 
tor magnus  and  the  obturator  externus,  no  other  agency  need  be 
invoked  than  hyper-tension. 

The  Hamstring  Muscles. 

I  have  already  stated  that  these  muscles  become,  under  certain 
circumstances,  the  guardians  of  the  sciatic  nerve.    In  their  guardian 

Fig.  30. 


action  they  illustrate  a  principle  inherent  in  all  muscular  fibre,  viz.. 
that  when  put  upon  the  stretch  it  exhibits  the  property  of  tendon  or 
ligament.    This  is  strikingly  brought  out  in  the  following  experiment ; 


36  INTBOD  UCTOR  Y  STUD  Y. 

If  a  pelvis,  resting  prone,  be  securely  bound  to  a  strong  table,  and 
the  thigh  with  flexed  leg  (Fig.  30)  be  permitted  to  hang  freely, 
the  thigh  will  hang  nearly  perpendicular.  If  now  the  support  of 
the  leg  be  gradually  removed,  the  leg  will  descend  until  arrested  by 
the  hamstring  muscles,  whose  tendons  will  stand  out  in  bold  relief  in 
the  popliteal  space.  If  the  leg  be  again  raised  and  suddenly  let  fall, 
it  will  be  so  suddenly  arrested  as  to  jar  the  whole  table,  and  a 
rebound  will  take  place  proportioned  to  the  height  and  suddenness 
of  the  fall.  The  sudden  checkino-  of  the  leo-  with  an  elastic  rebound 
demonstrates  the  important,  long-established,  but  not  sufficiently 
well-recognized,  principle  already  mentioned,  that  a  muscle,  when 
it  reaches  the  limit  of  extensibility,  becomes  a  tendon  or  ligament, 
and  if  the  force  continues,  the  muscle  must  rupture  in  some  part  or 
tear  from  its  bony  attachments,  or  the  bone  must  fracture  or  dislo- 


FlG.  31. 


cate.  Those  who  hold  that  muscles,  by  their  contractility,  aid  in 
the  reduction  of  dislocations,  must  depend  wholly  on  theory,  while 
the  agency  of  muscles  put  upon  the  stretch  can  be  demonstrated 
upon  the  cadaver.  In  experimental  work,  after  removing  every 
vestige  of  the  capsule,  I  have  been  able,  by  putting  the  psoas  mus- 
cle on  the  stretch,  to  restore  the  hip  by  the  very  principles  of  ma- 
nipulation that  Bigelow  has  so  happily  demonstrated  as  due  to  the 
Y-ligament.     In  manipulation  with  a  view  to  restore  a  dislocation 


THE  HAMSTRING  MUSCLES. 


37 


Fig.  32. 


one  often  experiences  a  locking  and  a  resistance,  due  in  part  to  the 
stretched  muscles. 

The  sudden  arrest  of  the  falling  leg  in  the  experiment  is  pos- 
sible only  with  normal  soundness  of  the  femur.  If  the  latter  be 
bi'oken  in  any  part  or  dislocated,  the  hamstring  muscles  will  not 
encounter  resistance  to  the  same  degree.  This  fact  can  be  turned 
to  good  account,  not  only  in  investigating  an  injury,  but  also  in 
determining  that  a  dislocated  limb  has  been  restored.  To  place  the 
tendons  on  the  stretch,  an  assistant  elevates  both  lower  extremities  by 
the  heels  (Fig.  31),  while  the  surgeon  marks  the  gradually  increasing 
tension  of  the  cords  in  the  pop- 
liteal space.  In  the  normal  limb 
the  tension  of  these  cords  will  be 
firm  and  resisting,  wholly  un- 
influenced by  muscular  action. 
It  will  be  steady  and  the  ten- 
dons will  feel  almost  like  so 
many  wires.  These  cords  will 
be  absent  in  case  of  fracture  or 
of  dorsal  dislocation.  Again, 
as  the  elevation  goes  on  the 
ascent  will  be  arrested  in  the 
sound  limb,  and,  if  the  assistant 
would  bring  the  limb  to  the  ver- 
tical, he  must  flex  the  leg  at  the 
knee.  (Fig.  32.)  Not  so  in  case 
of  dislocation  outward  or  of  frac- 
ture ;  the  extended  limb  can  easily 
be  placed  in  a  vertical  position. 

If  the  dislocation   be  inward 
instead   of  outward,  it    will    be 

impossible  to  raise  the  extended  limb  to  a  vertical  position.  (This  is 
also  true  of  the  normal  condition.)  The  reason  is  that,  in  dislocations 
inward,  the  head  rests  on  a  bony  foundation,  just  as  when  in  the 
socket,  and  flexion  makes  tense  the  fascia  lata  and  the  hamstring 
muscles.  To  decide  that  the  limb  is  dislocated  inward  one  should 
adduct  the  femur  —  this  is  impossible  when  the  head  lies  in  the 
thyroid  depression  upon  the  inner  plane. 

In  experimental  work  after  I  had  restored  the  femur  with  the  body 


3 8  I^^TB on  UCTOR  Y  STUD  Y. 

prone  (Fig.  30)  I  could  readily  assure  myself  that  the  restoration  was 
satisfactory  by  raising  slightly  the  foot  and  letting  it  fall,  while  at  the 
same  time  my  unoccupied  hand  rested  upon  the  great  trochanter.  If 
the  limb  were  restored,  the  fall  of  the  leg  would  simply  jar  the 
pelvis ;  but  if  it  was  dislocated,  the  trochanter  would  jump  beneath 
the  hand.  Although  this  experiment  has  little  clinical  value,  yet  it 
illustrates  well  the  principle  under  consideration,  that  a  muscle  when 
made  tense  deports  itself  like  a  ligament. 


A  STUDY  OF  THE  IMECHANISM  OF  DISLOCATIONS 
ARTIFICIALLY  PRODLX'ED. 

Many  of  the  earlier  experimenters  in  this  field  of  surgery  found 
it  expedient,  if  not  absolutely  necessary,  to  divide  the  capsule  sub- 
cutaneously  before  they  could  effect  dislocation. 

To  avoid  the  necessity  of  tenotomy  I  resorted  to  fixation  of  the 
pelvis  as  a  preliminary  step  in  my  investigations. 

It  may  be  objected  that  I  have  not  imitated  the  mechanism  through 
which  dislocation  occurs  any  more  exactly  than  those  whose  course 
I  wished  to  shun ;  but  upon  a  closer  study  it  will  be  seen  that,  in 
actual  life,  no  dislocation  ever  occurs  except  on  the  principle  of  the. 
lever  and  fulcrum,  and,  in  the  case  of  these  agents,  the  former  is 
ahvays  the  movable  and  the  latter  alivays  the  fixed  agent.  It  does 
not  afiFect  the  principle  whether,  in  the  causation  of  a  dislocation,  it 
occurs  when  a  man  is  slowly  walking  or  when  he  is  hurled  from  a 
rapidly  moving  car ;  whether  it  requires  a  minute  or  the  hundredth 
part  of  a  second.  In  every  case  the  lever  must  move  and  the  fulcrum 
must  he  fixed. 

When  a  person  steps  into  a  deep  hole,  and,  falling  forward,  dislo- 
cates his  hip,  the  mechanism  is  plainly  that  of  motion  and  fixation, 
lever  and  fulcrum.  If  a  man  suffers  the  same  accident  from  getting 
his  leg  caught  in  the  wheel  of  a  rapidly  moving  wagon,  the  same 
mechanical  principles  are  present,  viz.,  motion  and  fixation — the  lever 
and  fulcrum.  In  the  latter  case  the  inertia  of  the  body  represents 
the  fixation,  while  the  rapidity  of  the  revolving  wheel  twists  the  head 
out  of  its  socket  before  any  of  the  dislocating  energy  has  been  com- 
municated to  the  body.  This  is  illustrated  by  the  trick  of  snapping 
a  card  poised  upon  the  finger  from  beneath  a  penny,  without  dis- 


MECHANISM  OF  DISLOCA  TIONS  ARTIFICIALL  Y  PROD  UCED.     39 

turbing  the  penny.  The  penny  is  bound  down  by  inertia,  and  the 
solution  of  the  problem  is  to  communicate  motion  to  the  card  with- 
out communicating  any  to  the  penny.  By  a  slow  motion  this  trick 
is  impossible,  since  both  card  and  penny  move  together.  So,  in  my 
early  attempts  at  reduction  without  fixation,  my  tardy  movements 
w^ere  readily  communicated  to  the  trunk,  and  I  failed,  because  I  was 
not  imitating  the  traumatisms  of  actual  life.  In  mechanically  secur- 
ing the  pelvis,  i.  e.,  in  preliminary  fixation,  I  was  merely  immobilizing 
my  fulcrum,  and  ifi  this  I  was  following  to  the  letter  the  mechanism 
of  all  traumatic  dislocations. 

Fig.  33. 


Fig.  33  represents  part  of  a  dissecting-table.  Above  is  a  cross-bar  of  hickory,  three  and 
a  half  feet  long  and  one  and  a  half  inches  in  diameter.  An  oak  strip,  three  inches  wide 
and  of  the  same  length,  runs  parallel  beneath  the  table.  The  two  are  connected  by  iron 
rods  eighteen  inches  long.  Two  hooks  slip  along  the  hickory  rod.  At  the  end  of  the  table 
is  a  second  oak  board  that  passes  beneath  the  end  of  the  table  and  above  the  cross-bar. 
Two  iion  rods,  twelve  inches  long,  with  open  hooks,  are  seen  in  this  board.  The  apparatus 
■will  fit  any  post-mortem  or  dissecting-table,  and  the  cadaver  can  be  fastened  to  any  part  of 
it.  If  I  desire  to  operate  on  the  right  hip,  I  bring  the  subject  to  the  right-hand  corner  of  the 
table.  This  permits  me  to  make  any  desired  manipulation.  The  cross-bar  crosses  the  lumbar 
vertebrfe  above  the  pelvis ;  the  lower  hooks,  which  are  between  the  thighs,  are  now  con- 
nected to  the  hooks  on  the  cross-bar  by  means  of  a  bed-cord,  which  secures  the  pubic  por- 
tion of  the  pelvis.  Any  further  tightening  can  be  done  with  the  thumb-screws.  With 
this  the  pelvis  ea,n  be  secured  as  in  a  vise,  and  the  operator  can  watch  the  effect  of  every 
manipulation. 

No  further  advantage  was  anticipated  from  fixation  than  that  it 
would  enable  me  to  accomplish  my  purpose  ;  but  in  this  I  was  agree- 
ably surprised.     It  was  indeed  the  initiatory  step  to  a  series  of  most 


40 


INTROD  UCTOR  Y  STUD  Y. 


instructive  studies,  each  of  which  will  be  treated  at  length  in  its 
proper  place. 

The  instrument  that  I  found  of  great  service  to  me  is  seen  on  p.  39. 

After  fixation  dislocations  can  be  performed  by  unaided  manual 
effort,  and  the  process  may  be  carefully  watched.  The  factors  that 
enter  into  the  problem  are  simply  the  mechanical  powers,  viz.,  the 
lever,  fulcrum,  power,  and  weight.  These  present  interesting  points 
for  consideration,  and  will  be  taken  up  in  order. 

The  Lever.  If  a  lever  is  straight  and  round  (Fig.  34),  it  will 
make  no  difference  which  surface  is  exposed  to  the  fulcrum ;  but  if 


Fig.  34. 


Fig.  35. 
B 


m    rr-l 


±1 


HL 


.n 


W  X  Y  Z 

m  n  represents  a  plane  surface ;  w  x  y  z,  fulcra  of  equal  height  and  distance  from  their 
respective  levers ;  A  and  B  are  levers.  If  A  be  turned  to  the  right  or  left,  it  will  strike  a 
fulcrum.  If  B  be  turned  to  the  right,  it  cannot  touch  a  fulcrum,  owing  to  the  bend  in  it ; 
but  if  it  be  turned  to  the  left,  it  will  strike  the  fulcrum  sooner  than  if  it  had  no  bend  in 
it,  while  the  bend  in  the  lever  taken  together  with  the  fulcrum  will  enable  the  lever  to 
raise  a  weight  to  a  higher  point  than  a  plain  lever  could  do. 

it  is  bent  and  has  a  limited  range  of  motion,  as  upon  an  even  surface, 
one  position  may  make  it  wholly  useless  (Fig.  35,  dotted  line),  while 
another  surface  may  make  it  more  advantageous  than  a  straight  lever. 
In  the  latter  condition  the  outward  prominence  situated  at  the  iunc- 
tion  of  the  two  arms  of  the  lever  may  itself  constitute  an  additional 
fulcrum  and  enable  the  operator  to  raise  the  weight  much  higher 
than  could  be  done  with  a  straight  lever.  If  the  lever,  in  addition 
to  the  bend,  has  a  projection,  then  lever  and  fulcrum  would  be  repre- 
sented in  one  solid  piece,  and  such  an  instrument  could  be  made 
available  upon  a  plane  surface. 

Now,  the  femur  is  a  lever  whose  shaft  is  long  and  straight,  whose 
neck  joins  the  shaft  at  an  angle  of  130°,  and  is  provided  with  a 
trochanter — all  of  which  elements  may  be  the  occasion  of  disaster 


MECHANISM  OF  DISLOCATIONS  ARTIFICIALL  Y  PROD  UCED.     41 

to  the  joint  and  parts  composing  it.  The  shaft  of  the  femur  can 
hardly  be  used  as  a  lever  in  any  other  positions  than  in  abduction 
and  extension.  When  dislocations  take  place  through  rotation,  the 
bent  leg,  like  the  handle  of  a  crank,  becomes  the  long  arm  of  the 
lever,  and  the  neck  and  head  the  short  arm. 

The  Fulcrum.  Inseparable  from  the  lever,  without  which  the 
very  name  lever  would  have  no  meaning,  is  the  fulcrum.  Every 
quality  of  strength  and  reliability  that  is  essential  to  the  lever  must 
be  present  in  the  fulcrum.  In  one  quality  only  does  it  differ  from 
the  lever,  and  that  is  in  fixation.  The  fulcrum  is  the  pivot 
upon  which  both  arms  of  the  lever  move  ;  it  is  the  arbitrary  line 
or  division  from  which  both  arms  take  their  origin.  Its  effective- 
ness in  levers  of  the  first  class  depends  upon  its  position — the  nearer 
it  approaches  the  weight  the  greater  the  power  that  can  be  exerted. 

Under  the  normal  range  of  motion  no  part  of  the  pelvis  furnishes 
a  fulcrum,  but  in  hyper-abduction  (Fig.  36)  the  outer  rim  of  the 
socket  becomes  a  most  advantageous  fulcrum.     It  is  advantageous, 


Fig.  36 


FULCRUM 


because  it  yields  a  very  short  weight-arm  with  a  long  power-arm, 
and  because  the  weight,  i.  e.,  the  resistance  to  be  overcome  (that  of 
the  capsule),  lies  almost  directly  over  the  fulcrum.  In  experimental 
work  the  rupture  of  the  capsule  through  hyper-abduction  is  easier 
and  more  certain  than  in  any  other  way.  In  simple  hyper-extension 
the  rim  of  the  socket  forms  quite  an  advantageous  fulcrum  ;  but  in 
this  instance  the  resistance  is  far  greater,  inasmuch  as  the  anterior 
part  of  the  capsule  is  stronger  than  the  internal  part  of  it. 


42 


IXTROD  UCTOR  Y  STUB Y. 


Other  bony  fulcra  are  to  be  found,  though  not  one  furnishes  so 
short  a  weight-arm.  Thus,  the  sjreat  trochanter  is  broufjht  against 
the  tuberosity  of  the  ischium  in  extension  and  rotation  outward, 
using  the  bent  leg  as  a  lever.  In  hyper-flexion  the  knee  strikes 
the  abdomen  before  the  neck  strikes  the  rim  of  the  socket.' 


Fig. 


In  Fig.  37  is  represented  the  principle  just  stated,  that  a  beat  lever  may  sometimes 
be  unable  to  secure  a  fulcrum. 

In  marked  contrast  to  the  conditions  present  in  hyper-abduction 
are  those  in  adduction,  Avhere  we  find  the  same  lever,  but  bent  so 
that  no  part  of  the  neck  can  come  in  contact  with  the  rim  of  the 
socket.  Hyper-adduction  will  bring  the  shaft  against  the  pubes,  and 
the  result  may  be  a  fracture,  but  it  cannot  be  a  dislocation.  I  would 
therefore  emphasize  the  statement  just  made,  that  danger  of  dislo- 
cation is  inseparable  from  simple^  hyper-abduction,  because  an  advan- 
tageous bony  fulcrum  is  always  available,  \^hile  in  simple  hyper- 
adduction  it  is  impossible,  from  the  absence  of  a  fulcrum. 


1  By  the  word  simple  I  mean  that  no  other  motion  or  force,  such  as  rotation,  shall  be  added 
to  abduction  or  adduction. 


DISLOCATEON  THROUGH  LEVERAGE.  43 


DISLOCATION    THROUGH    LEVERAGE,   BUT    WITHOUT 
A  BONY  FULCRUM. 

In  all  dislocations  effected  through  leverage  a  fulcrum  is  indis- 
pensable. When  the  femur  is  flexed  and  adducted  no  bony  fulcrum 
is  available,  and  yet  this  is  one  of  the  situations  most  liable  to 
dislocation.  To  make  a  dislocation  possible  a  new  force  must  be 
supplied.  This  will  either  be  a  thrust,  i.  e.,  a  powerful  force  exerted  in 
the  long  axis  of  the  shaft,  or,  if  through  leverage,  it  must  he  through 
rotation.  In  all  efforts  at  rotation  the  bones  of  the  leg,  bent  at  right 
angles  to  the  long  axis  of  the  femur,  constitute  the  long  or  power- 
arm  ;  the  head  and  neck  constitute  the  short  or  weight-arm.  Ex- 
ternal rotation  has  never,  in  my  hands,  in  experimental  work  effected 
rupture  of  the  capsule,  but,  after  rupture,  through  hyper-abduction, 
external  rotation  with  extension  of  the  limb  will  bring  about  a 
dislocation  inAvard.  Internal  rotation,  on  the  contrary,  whether  the 
thigh  be  normally  extended  and  the  leg  used  as  a  crank  and  turned 
outward,  or  the  thigh  be  flexed  and  adducted,  with  similar  rotation, 
is  an  effective  measure  to  bring  about  dislocation.  The  mechanism 
is  the  same  under  all  circumstances  where  internal  rotation  is  con- 
cerned— there  is  no  bony  fulcrum.  Query,  What  are  the  nature  and 
position  of  the  fulcrum  ?  If  we  remove  every  structure  from  the 
joint  but  the  capsule,  it  will  be  readily  seen  that  by  internal  rota- 
tion the  strono;  ilio-femoral  ligament  becomes  wound  across  the  neck 
of  the  femur.  (Fig.  38.)  The  trochanter  has  been  rotated  up  and 
the  head  is  now  pressing  hard  against  the  postero-inferior  part  of 
the  capsule.  Under  these  circumstances  it  is  impossible  to  tell  what 
will  give  way ;  the  pressure  is  great  and  increases  as  rotation  ad- 
vances. By  this  manoeuvre  I  have  ruptured  the  ligaments  of  the 
knee-joint,  made  twist  fractures  of  the  shaft  and  of  the  neck  of  the 
femur,  ruptured  the  capsule  of  the  hip  in  its  postero-inferior  aspect, 
with  escape  of  the  head  downward  and  outward,  but  not  in  a  single 
instance  has  the  ilio-femoral  ligament  been  torn.  This  ligament 
therefore  acts  as  a  fulcrum  in  all  cases  of  rotation  inward,  and,  as 
rotation  outward^  never  enters  into  the  problem  of  rupture  of  the 
capsule,  it  can  almost  be  put  down  as  an  axiom  that,  if  dislocation 

1  See  Remarks,  p.  46. 


44 


INTR OD UCTOR  Y  STUD  Y. 


has  taken  place  through  flexion  and  adduction,  rotation  inward  ac- 
companied it.^  If  the  reader  will  now  compare  the  mechanism  of 
dislocation  brought  about  through  abduction  and  a  fixed  bony  ful- 
crum with  that  of  flexion,  adduction,  and  a  ligamentous  fulcrum,  he 
will  (I  am  inclined  to  think)  decide  that  the  former  is  by  far  the 
easier.     In  six  successive  attempts  to  dislocate  by  the  latter  method, 


Fig.  3S. 


The  design  of  Fig.  as  is  to  illustrate  the  relation  of  the  ilio-femoral  ligament  to  the  neck  ot 
the  femur  during  flexion  and  rotation  inward.  The  femur  is  represented  in  the  position  of 
abducticn,  merely  to  give  a  better  view  of  the  ligament  and  its  relations  to  the  neck. 


i.  g.,  by  rotation,  the  ligaments  of  the  knee  gave  way.  Failing  in 
this,  dislocation  was  accomplished  through  abduction,  with  a  bony 
fiilcrum. 

Po"wer.  This,  except  under  pathological  conditions,  is  always  an 
external  force,  which  must  be  exerted  through  the  femur.  The  power 
may  be  exerted  directly  upon  the  femur,  in  abduction  or  in  hyper- 
extension.  It  may  be  employed  indirectly  through  rotation,  in  which 
case  the  bent  leg  becomes  the  lever  upon  which  the  force  is  exerted, 

"Weight,  ^.  e..  Resistance.  This  lies  chiefly  in  the  capsule. 
Given  a  power  capable  of  breaking  the  lever  or  rupturing  the  cap- 
sule, and  the  result  will  depend,  in  a  great  measure,  upon  the  mode 
of  attack : 

>  Refer  to  "  Steps,"  p.  83. 


EXPERIMENTAL   WORK.  45 

1.  If  the  capsule  be  attacked  through  abduction,  there  is  the 
highest  probability  that  it  will  be  ruptured.     (Fig.  36.) 

2.  If  it  be  attacked  through  flexion,  adduction,  and  rotation  in- 
ward (Fig.  38),  the  ligaments  of  the  knee  may  give  way  ;  the  femur 
may  yield  through  twist  fracture,  or  the  capsule  will  be  torn. 

3.  If  the  attack  be  through  flexion,  adduction,  and  rotation  out- 
ward, the  capsule  will  resist  and  fracture  in  some  part  will  result. 


EXPERIMENTAL  WORK. 

The  following  is  a  record  of  only  a  few  of  the  many  experiments 
I  have  made.  In  many  no  new  fact  or  principle  .was  brought  out ; 
when,  however,  anything  unusual  occurred  a  record  has  been  entered 
in  its  proper  place. 

Experiment  I.  Attempt  made  to  dislocate  upward  and  back- 
ward, attacking  the  upper  outer  third  of  the  capsule. 

Subject :  Male  adult,  muscular,  about  twenty-four  years  of  age, 
about  forty-eight  hours  after  death.  Pelvis  fastened  securely,  limbs 
projecting  over  the  end  of  the  table.  Right  leg  flexed  on  the  thigh 
to  a  right  angle,  thigh  slightly  flexed  and  adducted.  Thigh  rotated 
outward  {i.  e.,  the  ankle  of  the  bent  leg  was  turned  inward  and  up- 
ward). This  brought  the  head  against  the  upper  and  strongest  part 
of  the  capsule ;  it  brought  the  great  trochanter  against  the  ischium. 
Result,  fracture  of  the  femur  in  the  lower  fourth. 

Experiments  II.  and  III.  I  repeated  this  experiment  in  two 
other  cases.  In  both  the  ligaments  of  the  knee  gave  way,  depriving 
me  of  the  bent  leg  as  a  lever. 

Remarks.  In  these  experiments  the  tuberosity  of  the  ischium 
was  probably  the  fulcrum.  By  rotation  outward  the  trochanter  was 
brought  against  it,  while  the  head  within  the  capsule  Avas  forced 
against  the  upper  front  part,  ^.  e.,  the  thickest  and  strongest  part. 
In  the  first  instance  the  shaft  broke  through  twist,  and  in  the  re- 
maining two  the  ligaments  of  the  knee  gave  way.  In  none  was  the 
capsule  ruptured. 

Experiment  IV.  Attempt  to  dislocate  outward  by  flexing  the 
thigh  on  the  abdomen.     Adduction  and  rotation  outward. 

Conditions :  Recent  cadaver,  male,  about  twenty-five  years  of 
age,  body  securely  fixed.     Right  femur  flexed,  adducted,  and  rotated 


46 


INTROD  UC'TOR  Y  STUD  Y. 


outward,  i.  e.,  the  bent  leg  was  used  as  a  crank  and  turned  inward. 
As  I  was  not  able  to  effect  the  displacement,  the  janitor  assisted  me, 
using  nothing  but  manual  force  upon  the  femur  and  bent  leg.^  Re- 
sult, fracture  of  the  pelvis  as  indicated  in  Fig.  39. 


Fig.  39. 


Remarks.  This  was  my  fourth  attempt  to  dislocate  by  means  of 
flexion,  adduction,  and  rotation  outward.,  i.  e.,  by  using  the  bent  leg 
as  a  lever  and  turning  it  inward.  In  two  the  ligaments  of  the  knee 
gave  way ;  in  one  the  shaft  of  the  femur  was  broken  in  the  lower 
third  ;  in  one  the  pelvis  fractured.  A  glance  at  the  figure  will  make 
it  clear  that  no  bony  fulcrum  can  be  made  available  in  this  mode  of 


'  The  rcivder  is  asked  to  explain  how  a  transverse  fracture  of  the  pubes  and  of  the  ilium 
could  result  from  a  twist  of  the  femur.  The  pelvis  was  fixed,  and  the  only  force  exerted 
was  manual  and  exerted  through  the  bent  leg.  Had  this  result  occurred  from  a  fall  or 
a  crush  the  unanimous  voice  would  be  in  favor  of  direct  violence.  In  this  case  it  was 
unquc-tionably  through  twist,  precisely  as  in  other  cases  I  produced  twist  fractures  of  the 
femur. 


EXPERIMENTAL   WORK.  47 

attempting  dislocation,  unless  the  neck  acts  upon  the  upper  part  of 
the  rim  of  the  socket.  The  resistance  to  dislocation  lies  chiefly  in 
the  upper  and  outer  part  of  the  capsule  ;  and  the  result  in  four  cases 
(all  young,  in  the  prime  of  development,  and  in  good  state  of  preser- 
vation as  far  as  the  ligaments  were  concerned)  clearly  shows  that  the 
head  cannot  be  made  to  escape  through  the  thickest  part  of  the  cap- 
sule by  flexion,  adduction,  and  rotation  outivard. 

Bigelow,  who  was  of  the  opinion  that  the  head  emerged  above  the 
obturator  internus  and  pyriformis  by  a  thrust  in  the  long  axis  of  the 
femur  when  it  was  extended  and  adducted,  was  unable  by  any  prac- 
tical method  to  produce  this  variety ;  and,  therefore,  he  divided  with 
a  bistoury  the  capsule  above  these  muscles  ;  and  then — strange  to  say 
— dislodged  the  head  by  flexion,  adduction,  and  rotation  outivard, 
and  not  hy  an  upward  thrust.  The  fact  that  7io  expeiHmenter  has 
been  able  to  dislocate  directly  upward  without  preliminary  tenotomy 
of  the  capsule,  taken  with  the  disastrous  results  of  my  four  cases, 
might  suggest  that,  in  actual  traumatic  dislocations,  some  easier  ivay 
is  found  for  the  head  to  reach  a  high  position  than  through  the 
thickest  part  of  the  capsule. 

In  the  foregoing  attempts  to  dislocate  the  head  of  the  femur  the 
resistance  was  solely  from,  the  capsule,  with  the  result  of  fracture  of 
the  femur,  rupture  of  the  ligaments  at  the  knee,  and  fracture  of  the 
pelvis.  Hence,  when  Sir  Astley  Cooper^  affirmed  that  ligaments 
present  little  strength  to  prevent  dislocations,  he  was  in  error. 

Dislocation  Produced  by  Rotation  Inward.  (See  Mechan- 
ism, Fig.  38.) 

Experiment  V.  Female,  about  fifty  years  old.  Pelvis  secured. 
Right  femur  flexed  to  a  perpendicular.  Leg  used  as  a  crank,  and 
turned  outward  [i.  e.,  inward  rotation).  Capsule  readily  ruptured, 
and  head  dislodged  downward  and  outward. 

Experiment  VI.  Left  femur  of  the  same  subject.  Hyper-flexion 
of  femur  upon  abdomen.  Flexed  leg  used  as  a  crank  and  rotated 
downward  and  outward  (?'.  e.,  inward  rotation  of  the  femur). 

Result,  dislocation  downward  and  outward,  with  complete  rupture 
of  the  obturator  externus,  quadratus  femoris,  obturator  internus,  and 
pyriformis.  In  reducing  this  case,  the  great  sciatic  nerve  was  seen 
to  stretch  over  the  head  as  it  was  passing  into  the  socket. 

1  Dislocations,  pp.  20,  21. 


48  INTRODUCTORY  STUDY. 

Experiment  VII.  Male,  sixty-one  years  old,  a  dissecting-room 
subject  that  had  been  abandoned  after  dissection.^  Capsule  and 
muscles  about  the  joint  in  good,  supple  condition.  Pelvis  secured. 
Left  femur  flexed  to  a  right  angle  and  leg  flexed  on  thigh.  Knee 
adducted  a  little  and  a  little  extended,  so  that  by  internal  rotation 
the  head  would  tend  to  burst  the  capsule  above  the  pyriformis.  Re- 
sult, fracture  of  the  neck,  partly  intra-  and  partly  extra-capsular. 
The  lesser  trochanter  remained  upon  a  large  spicule  that  adhered  to 
the  head. 

Experiment  YIII.  Right  femur.  Femur  flexed  to  perpen- 
dicular, leg  flexed  on  femur,  knee  gently  adducted  and  slightly 
extended,  as  in  previous  case.  Rotation  inward,  head  made  to  press 
against  the  capsule  above  the  pyriformis.  Result,  fracture  of  the 
neck  of  the  femur,  as  in  the  previous  case. 

Remarks  07i  Experiments  VII.  and  VIII.  The  head  was  made 
to  attack  the  outer  upper  part  of  the  capsule,  and  found  the  capsule 
stronger  than  the  agent  that  attacked  it. 

Experiment  IX.  Well-developed  colored  man,  about  thirty 
years  of  age.  Body  secured,  prone.  Right  limb.  Femur  flexed  at 
right  angles  to  pelvis.  Leg  at  right  angles  to  femur,  used  as  lever. 
Rotation  inward  [i.  e.,  ankle  drawn  outward).  Result,  ligaments  of 
knee  crackled  and  gave  way.  Dissected  everything  away  from  the 
hip-joint  but  the  capsule.  Limb  placed  in  the  same  position.  Rota- 
tion inward.  Rupture  of  capsule  ^o&tev'mvl^  from  femoral  attach- 
ment., hence  a  long  sleeve.     (Fig.  41.) 

Experiment  X.  Left  limb.  Femur  extended.  Leg  used  as  a 
crank  or  lever,  at  right  angles  to  femur.  Rotation  inward.  Liga- 
ments of  knee  gave  way.  After  removing  the  gluteus  maximus  I 
divided  the  capsule  close  to  the  femoral  attachment,  in  the  interspace 
between  the  tendons  of  the  pyriformis  and  obturator  internus.  Thus 
weakened,  the  head  was  with  difficulty  dislocated  outward  by  internal 
rotation. 

Observation  1.  In  both  limbs  the  capsule  proved  to  be  stronger 
than  the  ligaments  of  the  knee. 

Observation  2.     The  fact  that  dislocation  was  possible  in  the  right 

1  All  the  other  experiments  were  upon  fresh  subjects  in  which  the  ligaments  were  in 
almost  perfect  condition.  In  these  two,  although  the  body  had  been  on  the  dissecting-table 
for  at  least  a  month,  the  ligaments  proved  to  be  more  than  a  match  for  the  femurs. 


LESIONS  PRODUCED  IN  EXPERIMENTAL  WORK.  49 

limb  after  removing  the  muscles  would  strengthen  the  assumption 
that  the  muscles  contribute  to  the  safety  of  the  articulation. 

Observation  3.  From  experimental  study,  I  incline  to  the  opinion 
that  the  chief  agency  of  the  muscles  is  to  check  any  range  of  motion 
that  would  place  the  joint  in  jeopardy  ;  but  that,  when  the  joint  is 
once  put  to  the  test,  the  ligaments  are  the  main  safeguard. 

LESIONS  PRODUCED   IN  EXPERIMENTAL  WORK. 
THE  CAPSULE. 

After  dislocation  some  portion  of  the  capsule  still  connects  the 
femur  to  the  rim  of  the  socket.  It  was  formerly  believed  that  there 
was  no  special  portion  of  the  capsule  that  remained  untorn  after  a 
dislocation,  since  the  head  was  supposed  to  pass  directly  to  its  points 
of  destination.  The  study  of  autopsies,  on  the  contrary,  presents  a 
most  constant  escape  of  the  ilio-femoral  ligament.  In  experimental 
Avork  it  is  easy  to  see  why  this  portion  of  the  capsule  escapes,  since, 
by  manual  effort,  the  head  can  be  dislocated  only  in  situations  that 
do  not  subject  the  capsule  to  great  strain. 

The  rupture  of  the  capsule  through  rotation  is  due  to  torsion. 
Were  the  femur  a  straight  bone,  and  the  capsule  of  equal  length  and 
thickness,  it  would  be  diflScult  to  explain  why  one  part  should  yield 
through  torsion  before  another,  or  why  the  whole  should  not  rupture 
at  the  same  instant.  But  the  femur  is  not  a  straight  bone.  The 
neck  joining  the  shaft  at  an  angle  of  130°  cannot,  in  rotation,  exert 
equal  strain  on  all  parts  of  the  capsule.  When  the  capsule  is  torn 
through  torsion  the  lesion  is  invariably  extensive.  With  the  excep- 
tion of  the  ilio-femoral  ligament,  all  parts  of  the  capsule  have  been 
torn  in  pathological  studies  of  dislocations. 

A  question  of  vital  importance  to  decide  is  the  possibility  of  dis- 
locating the  head  through  a  slit  in  the  capsule.  It  always  has  been, 
and  probably  always  will  be,  a  very  universal  belief  that  the  head 
can  be  buttonholed  by  the  capsule,  and  that  this  is  one  of  the  diffi- 
culties that  skill  cannot  overcome. 

Morris,^  after  making  a  series  of  dislocations  and  finding  the 
rent  invariably  greater  than  the  diameter  of  the  head,  resorted  to  the 
following  expedient :    Prior  to  any  attempt  at  dislocation   he  slit 

1  See  a  most  instructive  article  on  this  subject  in  Medico-Chirurg.  Trans.,  vol.  Ix.,  by  Henry 
Morris,  F.R.C.S.. 

4 


50  INTBOD  UCTOB  Y  STUD  Y. 

the  capsule  longitudinally,  then  dislocated,  and  found,  instead  of 
buttonholing,  a  rent  as  capacious  as  in  any  previous  experiment. 

Not  wishing  to  repeat  Morris's  work,  I  exposed  the  capsule,  and, 
instead  of  making  a  slit,  I  removed  a  circular  disk  from  the  capsule 
nearly  large  enough  to  permit  the  escape  of  the  head,  thinking  that 
the  borders  of  the  opening  would  yield  and  let  the  head  through 
without  further  laceration  ;  but  as  pressure  was  brought  against  it 
the  tense  marginal  fibres  snapped,  fibre  by  fibre,  and  the  head  made 
its  escape  through  an  opening  ample  for  its  easy  return.  I  dare  not 
say  that  a  fissure  in  the  capsule  is  impossible,  but  I  insist  that  it  is 
extremely  improbable.  I  dare  not  say  that  it  is  impossible,  but  I 
claim  that  no  teacher  has  a  right  to  enroll  it  among  the  obstacles  to 
the  reduction  of  a  dislocated  hip  until  he  has  proved  by  experi- 
mental work  its  possibility.  I  therefore  join  Morris  in  an  earnest 
protest  against  a  most  improbable  theory,  the  legitimate  fruits  of 
which  are  either  unwarranted  rudeness,  with  a  view  to  enlarge  the 
rent,  or  despair  and  abandonment  from  an  imaginary  unsurmount- 
able  obstacle.  Obstacles  there  really  are  to  reductions,  but  the 
sooner  we  abandon  the  chimerical  slit  in  the  capsule  the  sooner  the 
attention  of  the  profession  will  be  turned  to  the  possible  obstacles. 

Experimental  study  will  readily  convince  anyone  of  the  correct- 
ness of  the  views  just  stated,  but  the  plausibility  of  the  argument  is 
strengthened  by  the  following  considerations  : 

First,  of  the  shape  of  the  head  of  the  femur.  It  must  always  be 
the  head  of  the  femur  that  produces  the  laceration  in  the  capsule. 
Were  the  head  narrow,  square,  triangular,  or  oblong  the  rent  in  the 
capsule  would  necessarily  vary  greatly.  On  the  contrary,  the  head 
is  spherical,  and,  no  matter  from  what  quarter  the  capsule  is  attacked, 
the  round,  smooth  surface  of  the  head  is  the  effective  disruptive  agent. 

Second.  The  rupture-force  is  always  exerted  on  the  inner  surface 
of  the  capsule,  ^.  e.,  from  within  outward.  While  the  leverage  is 
effected  through  the  femur  or  leg,  the  head,  which  is  the  extreme 
point  of  the  short  arm  of  the  lever,  is  forced  against  the  inner  surface 
of  the  resisting  capsule. 

Third.  The  structure  of  the  capsule  is  fibrous.  It  cannot  stretch 
suddenly.  The  round  head  of  the  femur  is  forced  against  the  short 
resisting  cylindrical  capsule,  and  makes  every  fibre  pressed  upon 
tense  at  the  same  instant.  Often  the  first  fibres  to  yield  are  those 
overlying  the  greatest  convexity  of  the  head.     As  these  yield  the 


LESIONS  PRODUCED  IN  EXPERIMENTAL  WORK.  51 

force  falls  upon  succeeding  fibres,  and  thus  each  fibre  made  tense 
snaps  before  the  resistless  advance  of  the  head. 

When  a  dislocation  takes  place  by  a  single  uncomplicated  force, 
as  by  hyper- abduction,  the  rent  is  confined  to  the  fibres  pressed 
upon,  and  represents  a  minimum  degree  of  laceration,  equal  trans- 
versely to  the  diameter  of  the  head.  Even  this  may  render  the 
restoration  difficult.  When  dislocations  are  due  to  a  twist,  as  by 
rotation,  the  rent  is  always  extensive,  embracing  fully  two-thirds 
of  the  periphery  of  the  capsule. 

After  dislocation  takes  place  the  head  can  do  no  more  harm  to 
the  capsule.  Further  efforts  to  enlarge  the  rent  must  be  made 
through  rotation  and  circumduction,  which  bring  the  neck  of  the 
femur  ag-ainst  the  border  of  the  rent.  To  enlarge  the  rent  in  the 
capsule  the  head  must  be  made  to  plow  through  any  structure  that 
may  lie  in  its  path,  doing  much  destruction  to  muscles  without  any 
positive  assurance  of  rendering  reduction  in  the  slightest  degree 
easier.  A  point  that  should  always  be  borne  in  mind  is,  that  when 
the  femur  after  dislocation  presents  marked  deformity  there  is  a 
minimum  laceration  of  the  capsule,  and  the  head  lies  near  the 
socket ;  while,  when  the  deformity  (i.  e.,  the  constraint)  is  slight, 
there  has  been  free  laceration  of  the  capsule. 

The  INo-femoral  Ligament.  This  I  have  never  torn  from  its 
pelvic  attachment.  Bigelow,  in  describing  a  subspinous  disloca- 
tion, expressed  the  belief  that  the  head  had  reached  that  position 
through  direct  upward  dislocation,  and  in  its  ascent  had  stripped  up 
the  (upper)  pelvic  attachment  of  the  ligament.  I  record  this  only 
to  dissent  from  it.  In  experimental  work  I  have  produced  a  sub- 
spinous luxation,  but  not  through  direct  upward  thrust.  The  lower, 
or  femoral,  attachments  of  the  Y-ligament  are  not  so  secure.  I  have 
twice  torn  the  outer  and  once  the  inner  branch  from  its  attachment. 
In  most  instances  the  entire  ilio-femoral  ligament  remains  intact. 


52 


INTR OD  UCTOB  Y  STUD  Y. 


Position  of  Rent  in  Capsule. 

A  matter  of  the  greatest  practical  importance  is  the  position  of 
the  rent  in  the  capsule.  All  the  j^ossible  lesions  may  be  arranged 
under  three  general  classifications  : 

1.  Those  in  which  the  capsule  is  torn  from  its  acetabular  or  pelvic 
insertion.  (Fig.  40.)  I  have  torn  capsule  and  periosteum  from 
the  rim  of  the  socket.  In  this  class  of  lesions  there  can  be  no 
possible  obstruction  from  the  capsule  to  an  easy  replacement,  as 
no  part  of  it  can  be  driven  before  the  head  into  the  socket.  The 
torn  capsule,  under  such  circumstances,  must  follow  the  femur  in  every 
displacement  inward  or  outward,  and  in  all  efforts  at  reduction. 

Fig.  40. 


2.  Those  in  which  the  rent  is  between  the  attachments,  or  runs 
obliquely  from  one  attachment  to  the  other.  (Fig.  41.)  In  this 
lesion  the  part  of  the  capsule  that  is  attached  to  the  acetabulum  may 
Decome  aetached  from  the  surrounding  muscles  and  driven  before 
the  head  into  the  socket  during  the  act  of  replacement.  In  such  a 
case  only  a  limited  amount  could  be  driven  into  the  socket — scarcely 
enough  to  be  recognizable,  yet  enough  to  produce  mischief. 


LESIONS  PRODUCED  IN  EXPERIMENTAL  WORK,  53 

Fig.  41. 


3.  Those  in  which  the  capsule  is  torn  from  its  femoral  attach- 
ment.    (Fig.  42.)     This  I  believe  to  be  the  most  frequent  obstacle 


i^IG.  42. 


54 


INTRODUCTORY  STUDY. 


to  reduction.  In  this  lesion  the  capsule  remains  entire  or  nearly  so 
at  its  acetabular  portion,  and  as  this  is  the  easiest  point  of  entrance 
for  the  dislocated  head  the  capsule  is  likely  to  resist  reduction,  and 
if  vigorous  efforts  are  instituted  the  head  will  push  the  capsule  before 
it  into  the  socket. 

I  have  produced  all  these  lesions  in  experimental  work,  and  in- 
cline to  the  belief  that  the  character  of  the  lesion  must  vary  with 
the  nature  of  the  vulnerating  force.  If  dislocation  be  effected  through 
abduction^  the  head  of  the  femur  tends  to  strike  the  capsule  (Fig-  67) 
at  a  point  somewhat  remote  from  its  acetabular  attachment,  and 
hence  the  greatest  point  of  strain  will  be  midway  between  the  attach- 
ments or  near  its  femoral  and  thinnest  parts,  while,  on  the  contrary, 
when  the  femur  is  dislocated  during  adduction  the  head  is  driven 
toward  the  socket  and  its  greatest  point  of  strain  upon  the  capsule 
is  at  its  acetabular  attachment.  If  in  a  given  recent  case  of  dislo- 
cation of  the  hip  in  which  perfect  replacement  was  found  impossible, 
it  could  be  clearly  shown  that  the  accident  occurred  through  flexion 
and  abduction,  I  would  incline  strongly  to  the  belief  that  the  obstacle 
was  of  the  nature  shown  in  class  third — Fig.  42. 


The  three  foregoing  figures  are  reproduced  in  miniature  to  enable 
the  reader  to  contrast  at  a  glance  the  three  classifications  of  lesions. 

I  have  considered  this  topic  of  sufficient  importance  to  illustrate 
it  more  fully.  The  reader  will  notice  on  the  opposite  page  three  series 
of  illustrations.  In  each,  the  first  figure  in  the  series  represents  the 
head  in  the  socket,  and  one  variety  of  lesion  of  the  capsule.  The 
second  figure  in  each  series  represents  the  manner  in  which  the  cap- 
sule will  deport  itself  during  any  variety  of  displacement.  The  third 
figure  in  each  series  shows  the  possible  effect  upon  the  capsule  of 
replacement.  There  is  an  important  principle  involved  here ;  and 
unless  it  is  fully  comprehended,  arguments  later  on  will  fail  to  con- 
vince. 


lesiojs^s  produced  in  experimental  work. 


55 


Illustrated  resume  of  the  three  varieties  of  lesions  of  the  capsule, 
showing : 

X.  The  position  of  the  rent  in  the  capsule. 

Y.  The  deportment  of  torn  capsule  during  dislocation. 

Z.  The  effect  of  dislocation  upon  the  capsule. 


Fig.  43. 
First  Series. 

y. 


Rent  close  to  socket. 


Capsule  follows  femur       Capsule  restored  by  reduc- 
in  displacement.  tion. 


Fig.  44. 

Second  Series. 

Y. 


Rent  midway  in  capsule.    Part  must  follow  femur,    Part  attached  to  rim  may  be, 
part  cannot.  and  often    is,  inverted  in 

reduction. 


Fig.  45. 

Thirb  Series. 

Y. 


Rent  close  to  femoral    Head  escapes,  leaving  cap-    Reduction  extremely  likely 
attachment.  sule  as  a  sleeve  behind,       to   place  the   head  upon 

covering  the  socket.  capsule,  not  in  socket. 


56 


INTRODUCTORY  STUDY. 


Lesions  in  Muscles. 

The  lesions  in  the  muscles  are  due  either  to  overstretchincr  or 
to  direct  violence. 

Overstretching-.  Muscles  are  easily  torn  in  manipulations  upon 
the  cadaver.  It  is  impossible  after  cadaveric  rigidity  to  dislocate 
without  rupturing  strong  muscles,  such  as  the  adductors  (Fig.  46), 
which  reach  their  limit  of  tension  before  the  capsule  is  ruptured  or 


Fig.  46. 


the  head  escapes  from  the  socket.  This  condition  would  not  be 
present  to  the  same  degree  in  the  living,  and  yet  it  affords  an  ex- 
planation of  many  of  the  lesions.  How  else  can  we  explain  the  rupture 
in  the  middle  of  the  adductor  longus,  the  gracilis,  or  the  pectineus  ? 
One  of  the  most  constant  lesions  found  in  autopsies  and  experimental 
work  is  rupture  of  the  pectineus  ;  and  this  muscle  is  not  touched  by 
the  head  of  the  femur  in  dislocations  either  inward  or  outward. 


LESIONS  PRODUCED  IN  EXPERIMENTAL   WORK.  57 

Rupture  of  Muscles  from  Direct  Contact.  By  this  I  mean 
the  havoc  produced  by  the  dislocated  head  plowing  through  all  mus- 
cular structure  within  reach.  It  is  possible  for  the  head  to  be  com- 
pletely dislocated  without  doing  material  mischief  beyond  rupture  of 
the  capsule.^  The  head  may  be  dislocated  inward,  and  if  any  mis- 
chief attend  it,  it  may  be  a  trifling  laceration  of  some  fibres  of  the 
obturator  externus.  By  a  glance  at  Fig.  47  it  will  be  seen  that  all 
the  muscles  that  extend  from  the  antero-lateral  aspect  of  the  pelvis 
to  the  shaft  have  their  origins  at  the  boundary  and  would  not  be 
injured  by  a  simple  primary  inward  or  outward  displacement.  Be- 
sides, too,  the  direction  of  displacement  when  the  thigh  is  abducted 
is  in  the  main  nearly  parallel  with  the  muscles,  which  would  favor 
their  escape. 

Fig.  47. 


After  a  dislocation  occurs  the  head  can  be  made  to  move  in  a  circle 
of  which  the  untorn  capsule  and  the  neck  constitute  the  radius.  If 
the  thigh  be  kept  nearly  perpendicular  and  the  knee  be  circumducted 
through  a  small  circle,  the  corresponding  circle  in  which  the  head  of 
the  femur  will  move  will  be  near  the  margin  of  the  socket ;  while 
larger  sweeps  of  the  knee  will  necessitate  correspondingly  larger  and 
more  disastrous  sweeps  of  the  head. 

In  Fig.  48  I  have  represented  two  arcs  of  circles.    Between  them, 

1  See  case  of  Robert  S— ,  p.  69. 


58 


IXTR OD  UCTOR  Y  STUD  Y. 


upon  the  ischium,  I  represent  the  strong  tendon  of  origin  of  the 
hamstring  muscles — one  of  the  important  structures  connected  with 
this  subject.  If  the  head  take  the  smaller  circle,  it  will  go  above 
this  tendon  ;  but  if  it  take  the  greater  circle,  and  if  at  the  same  time 
the  hamstring  muscles  are  made  tense  by  extension  of  the  leg  on  the 
thigh,  the  head  would  be  arrested  either  in  the  perineum  or  upon  the 
ischium,  as  it  could  not  pass  the  tendon. 

If  the  head  be  dislocated  primarily  inward  upon  the  pubic  plane, 
and  then  by  rotation  be  turned  outward  upon  the  dorsal  plane,  it 


Fig.  48. 


The  dotted  lines  represent  arcs  of  circles,  of  which  the  remnant  of  untorn  capsule  and 
the  added  length  of  the  neck  of  the  femur  represent  the  radius.  By  varying  the  position  of 
the  knee  an  infinite  number  of  arcs  could  be  described .    (See  Fig.  102.) 

must  burst  through  the  great  muscular  septum  that  separates  the 
femoral  vessels  from  the  sciatic  nerve.  In  Fig.  49  I  have  represented 
the  head  dislocated  inward,  and  about  to  be  shifted  by  inward  rota- 
tion to  the  outer  plane.  Two  muscles  are  in  the  way  :  the  quadratus 
femoris,  which  cannot  escape  when  the  head  is  shifted  from  an 
inward  (thyroid)  to  an  outward  (dorsal)  position,  and  with  it  some  of 
the  fibres  of  the  adductor  magnus.  The  adductor  brevis  is  often 
mentioned  among  the  torn  muscles  ;  but  the  lesion  is  probably  always 


LESIONS  PRODUCED  IN  EXPERIMENTAL  WORK. 


59 


the  result  of  overstretching,  and  not  due  to  direct  contact.  As  the 
head  forces  its  way  outward,  it  strikes  the  obturator  externus  and 
tears  it  in  two  ;  then,  in  turn,  the  quadratus  and  short  upper  fibres 
of  the  great  adductor,  all  of  Avhich  lesions  are  unavoidable  when  a 
primary  inward  dislocation  is  shifted  to  an  outward. 


Fig.  49. 


In  direct  dorsal  (i.  e.,  outward)  dislocations,  those  that  I  have 
produced  by  rotation  inward,  the  thigh  being  flexed  or  extended,  the 
capsule  is  rent  in  the  postero-inferior  aspect  and  the  head  may  de- 
scend between  the  obturator  externus  and  internus  (Fig.  51)  without 
rupture  of  either.^  If  this  accident  occurs  during  hyper-flexion  of  the 
thigh,  though  the  obturators  escape,  the  gluteus  maximus,  which  must 
be  tense  at  the  instant  of  escape,  will  be  bruised,  lacerated,  or  trans- 
fixed.^ 

Re'sume  of  Muscular  Lesions.  When  dislocations  occur 
through  leverage  of  the  shaft  of  the  femur — as,  for  instance,  during 

1  G.  M.  Humphrey  thinks  this  the  most  frequent  form  of  dislocation  (Lancet,  Nov.  27, 1886). 
Although  the  position  is  frequent,  the  entire  escape  of  the  muscles  must  be  very  infrequent. 
-  See  Case  IV.,  p.  65. 


60 


INTROD  UCTOR  Y  STUD  Y. 


abduction — the  long  muscles  are  torn  prior  to  dislocation.  It  is 
possible  for  these  muscles  to  be  torn  without  dislocation  taking  place. 
When  dislocations  occur  through  rotation  inward,  only  the  pyri- 
formis,  the  two  obturators,  and  the  quadratus  are  put  upon  the 
stretch.  These  may  rupture  through  overstretching ;  they  may  be 
torn  by  the  head  of  the  femur  as  it  bursts  through  the  capsule. 

Fig.  50. 


The  illustration  represents  the  head  restored  to  its  socket  after  a  primary  inward  disloca- 
tion has  been  shifted  to  an  outward  and  then  restored.  Note  the  area  of  the  lesion  and 
how  the  nerve  must  he  implicated  in  the  reparative  processes. 

If  the  head  escapes  through  rotation  inward  and  strong  flexion, 
the  gluteus  maximus  can  hardly  escape  laceration. 

If  the  head  escapes  inward,  every  rotator  muscle  may  escape. 

After  a  primary  inward  luxation  an  attempt  to  convert  it  into  a 
dorsal  will  rupture  the  obturator  externus  and  quadratus  femoris. 

The  head  may  escape  outward  between  the  obturators  without 
injuring  either,  through  rotation  inward.  (Fig.  51.)  Usually  the 
obturator  internus  is  torn. 

Muscles  are  torn  in  the  steps  of  dislocation  prior  to,  coincident 


PATHOLOGY. 


61 


with,  and  after  the  displacements.    In  rare  instances  they  all  escape. 
(See  p.  69.) 


Fig.  51. 


The  sciatic  nerve  has  been  twice  reported  torn  completely  in  two. 
It  has  been  lacerated,  bruised,  its  fibres  separated,  and  its  sheath 
filled  with  blood.  It  has  been  caught  up  repeatedly  by  experimenters 
and  carried  across  the  neck  in  reductions.  Partial  persistent  and 
permanent  paralyses  are  reported  as  sequelne  of  otherwise  successful 
reductions.  The  anterior  cutaneous  nerve  would  probably  be  stretched 
across  the  head  or  neck  if  a  thyroid  were  converted  into  a  subspinous. 


PATHOLOGY. 

No  better  proof  of  the  value  of  the  foregoing  experimental  work 
need  be  adduced  than  that  it  is  fully  and  minutely  corroborated  by 
dissections  of  actual  traumatisms.  The  author  has  not  striven  to 
make  a  large  collection  of  cases.  The  few  that  follow  illustrate  im- 
portant points;  except  in  a  few  instances,  duplicate  injuries  have 
been  rejected. 

Case  I. — A  man,  sixty  years  old,  was  killed  by  a  fall  from  a  ladder. 
Symptoms :  Right  leg  apparently,  but  not  actually,  much  shortened  ;  was 
inverted  and  separated  from  its  fellow;  the  trochanter  major  was  further  re- 
moved from  the  spine  of  the  ilium  than  normal ;  the  head  could  be  felt 
toward  the  back  of  the  pelvis ;  the  limb  could  be  flexed,  but  could  not  be 
rotated  outward. 

DissGction.  On  removal  of  the  gluteus  maximus  the  head  was  found  below 
the  obturator  internus  (Fig.  52),  which,  with  the  great  sciatic  nerve,  was 
stretched  over  the  neck  of  the  femur.     The  obturator  externus  and  quad- 


62 


INTRODUCTORY  STUDY. 


ratus  femoris  were  torn  in  two.  Some  of  the  deep  fibres  of  the  gluteus 
medius  were  torn  across.  The  capsule  was  rent  at  its  inner  and  lower 
aspect,  where  it  was  torn  from  the  neck  of  the  femur.  The  ligamentum  teres 
was  torn  from  the  head  of  the  femur. — Richard  Quain,  Medical  Times, 
vol.  xviii.  p.  205. 

Fk; 


Remarks.^  The  upward  progress  of  the  head  was  arrested  by  the 
nerve  and  the  obturator  internus.  Morris  has  asserted  that  the  nerve 
presents  a  more  reasonable  check  than  does  Bigelow's  position, 
known  as  "  dorsal  below  the  tendon."  The  mode  of  rupture  of  the 
obturator  externus  and  quadratus  femoris,  with  hooking  up  of  the 
nerve,  can  be  explained  in  two  ways :  The  head  might  have  been 
dislocated  primarily  inward,  and  then  by  unexpended  force  shifted 
outward.  If  such  was  the  case,  the  head  tore  its  way  through  the 
two  muscles  and  hooked  up  the  nerve.     In  the  other — and  to  my 


1  The  "  remarks"  after  cases  in  pathology  are  by  the  author  of  this  work,  and  the  reader 
may  give  them  whatever  consideration  he  thinks  them  entitled  to. 


PATHOLOGY. 


63 


mind  the  more  plausible — the  dislocation  took  place  during  forced 
flexion  with  rotation  inward.  Forced  flexion  would  make  tense  the 
obturator  externus  and  the  quadratus  femoris,  and,  at  the  same  time, 
draw  the  nerve  down  closely  upon  the  quadratus  as  it  crosses  the 
neck  of  the  femur.  Now,  while  in  this  condition,  if  rotation  inward 
be  added — a  manoeuvre  calculated  to  luxate  outward — the  two  mus- 
cles would  be  torn  either  through  overstretching,  or  through  direct 
contact,  and  the  nerve  would  be  readily  caught  over  the  neck  as  the 
head  fell  outward. 


Case  II. — I.  D.,  twenty-nine  years  old,  was  run  over  by  a  railroad  train, 
receiving  injuries  from  which  he  died,  with  symptoms  of  septicaemia,  four- 
teen days  after  the  accident.     Injury  to  the  hip.     Symptoms :    The  left 


Fig.  53. 


thigh,  leg,  and  foot  were  inverted ;  the  knee  was  directed  inward,  and  the 
thigh  was  slightly  flexed.  The  shortening,  if  any,  did  not  exceed  half 
an  inch. 

Dissection.   On  removing  the  overlying  structures  the  head  was  found 
with  the  obturator  internus  and  gemelli  above  it,  and  below  it  w^-"  " 
ruptured  obturator  externus  and  quadratus  femoris.     The  head  W 


64 


IXTR OD UCTOR Y  STUDY. 


vented  from  ascending  upon  the  ilium  by  the  obturator  internus.  It 
pressed  so  tightly  upon  the  head  that  it  produced  a  distinct  groove  in  the 
cartilage.  The  capsule  was  rent  in  its  posterior  half  and  torn  at  its  femoral 
attachment.  The  mass  of  detached  capsule,  remaining  attached  to  the 
(Fig.  53)  margin  of  the  acetabulum,  formed,  as  it  became  inverted  by  attempts 
to  reduce  the  head,  some  obstruction  to  its  return. — Wm.  Adams,  Trans.  Path, 
Soc,  London,  vol.  xxi. 

Remarks.  The  reader  will  especially  note  the  variety  of  rupture 
of  the  capsule :  it  was  from  its  femoral  attachment,  making  a  cuff 
for  the  socket.  (Fig.  42.)  Although  the  difficulty  was  laid  bare  by 
the  scalpel,  and  the  surgeon  could  use  his  eyes  in  efforts  at  restoration, 
still  the  capsule  would  turn  in  before  the  head.  The  rupture  of  the 
obturator  externus  and  quadratus  femoris  was — as  in  the  previous 
case — probably  due  to  rotation  inward,  which,  with  flexion,  would 
cause  their  rupture  by  tension. 


Case  III. — Cabman,  crushed  between  cab  and  house,  dying  in  a  few 

minutes. 

Fig.  54. 


PATHOLOGY.  65 

Dissection.  On  removing  the  gluteus  maximus  the  head  was  found  mid- 
way between  the  socket  and  the  great  sciatic  foramen.  The  head  lay  upon 
the  pyriformis,  gemellus  superior,  and  obturator  internus  muscles.  All  these 
muscles  retained  their  cellular  and  fibrous  attachments  to  the  torn  capsule. 
The  quadratus  femoris  was  but  slightly  torn  on  its  upper  border.  The 
gemellus  inferior  was  completely  raptured,  and  so  were  some  inferior  fibres 
of  the  obturator  internus.  At  least  half  of  the  fibres  of  the  pyriformis  were 
torn.  The  obturator  externus  was  but  slightly  injured ;  some  of  its  muscular 
fibres  were  detached  from  its  tendon.  The  tendon  of  the  obturator  in- 
ternus was  tightly  stretched  in  front  of,  and  the  tendon  of  the  obturator 
exturnus  tightly  stretched  behind,  the  neck  of  the  femur. — Morris,  Med.- 
Chirurg.  Trans.,  vol.  Ix. 

Remarks.  If  the  reader  will  turn  back,  he  will  see  how  the  head 
may  be  dislocated  between  the  two  obturators  without  rupturing 
either.  This  condition  will  also  su2;o;est  how,  in  the  livincr,  an 
attempt  at  reduction  by  flexion  and  circumduction  might  readily  fail. 

Case  IV. — J.  A.,  injured  by  a  great  weight  falling  upon  him,  dying  the 
same  day.  At  the  autopsy  there  were  found  a  rupture  of  the  bladder,  a 
fracture  of  the  ramus  of  the  pubes  into  the  foramen  ovale  of  the  right  side, 
and  a  separation  at  the  symphysis  pubis  and  at  the  sacro-sciatic  junction. 
On  dissection,  the  gluteus  maximus  was  found  nearly  torn  through,  with 
the  head  imbedded  in  its  substance ;  the  pyriformis  was  ruptured  and  the 
superior  gemellus  was  partly  ruptured ;  the  gluteus  minimus  was  so  com- 
pletely destroyed  that  its  remains  could  with  difficulty  be  recognized ;  the 
ligamentum  teres  was  torn  from  the  head  ;  the  head  lay  upon  the  gemelli  and 
the  sacro-sciatic  nerve ;  the  capsule  was  extensively  torn  close  to  the  ace- 
tabular attachment. — James  Syme,  Lond.  and  Edin.  Monthly,  1843. 

Remarks.  How  did  this  dislocation  take  place  ?  Through  direct 
thrust?  Under  these  circumstances  the  dislodgino;  head  would  have 
found  the  gluteus  maximus  in  a  state  of  complete  relaxation  and  not 
in  a  relation  to  it  to  oppose  it.  But  if  the  man  were  "  doubled  up," 
as  is  probable,  then  we  can  account  for  the  fracture  of  the  pelvis  and 
the  rupture  of  the  bladder,  while  a  dislocation  taking  place  when  a 
man  is  doubled  up  would  find  the  gluteus  stretched  tightly  over  the 
head,  and  rupture  or  transfixion  probable.  Note  in  this  case  that 
the  capsule  is  torn  from  the  socket.^ 

Case  Y. — C.  D.,  died  a  few  hours  after  admission  to  the  London  Hospi- 
tal. The  dislocation  had  been  reduced  by  manipulation,  the  head  passing 
from  the  dorsal  position  to  the  obturator,  and  thence  into  the  socket. 

On  dissection,  no  external  evidence  of  injury  was  found.     On  removing 

1  See  p.  88. 
5 


Q Q  INTR OB UCTOR Y  STUDY. 

the  gluteus  maximus,  the  bursa  between  it  and  the  vastus  externus  was 
found  to  be  ruptured  and  filled  with  blood.  The  sheath  of  the  great 
sciatic  nerve  ivas  distended  with  blood,  and  the  nerve  fibres  were  separated  from 
one  another.  The  posterior  fibres  of  the  gluteus  minimus  were  torn  across, 
and  the  cellular  tissue  beneath  the  muscle  was  filled  with  blood.  The 
quadratus  femoris  was  torn  completely  in  two,  and  the  uppermost  fibres  of 
the  adductor  magnus  and  some  fibres  of  the  gemelli  and  obturator  internus 
muscles  were  lacerated.  The  capsule  was  perfect  in  front  and  above,  but 
torn  in  its  posterior  part.  The  ligamentum  teres  was  torn  off  close  to  the 
head  of  the  femur. — J.  McCarthy,  Lancet,  1874,  ii.  13. 

Remarks.  How  is  it  possible  to  have  the  capsule  complete  in  front 
and  above,  and  yet  have  a  complete  rupture  of  the  quadratus  femoris 
take  place  ?  Answer.  By  flexion  and  rotation  inward  ;  the  laceration 
being  due  to  overstretching.  It  could  not  have  been  done  by  direct 
contact  with  the  head,  for  the  capsule,  not  being  torn  in  front,  would 
not  have  permitted  the  head  to  escape  in  that  direction.  By  flexion 
and  rotation  inward  the  nerve-injury  could  also  be  readily  explained. 

Case  VI. — W.  A.,  injured  by  falling  timbers,  admitted  to  the  London 
Hospital  with  the  following  symptoms :  Right  leg  two  and  a  half  inches 
longer  than  its  fellow ;  trochanter  major  less  prominent ;  foot  and  knee 
widely  separated  from  its  fellow.  No  attempt  at  reduction  was  made, 
owing  to  the  patient's  collapsed  condition.  When  he  rallied  a  little  the 
nurses,  in  changing  his  position  in  bed,  restored  the  dislocation.  Death  on 
the  third  day. 

On  dissection  of  the  hip  there  was  found  evidence  of  contusion  on  the 
outer  aspect  of  the  hip.  Blood  was  found  extravasated  between  the  mus- 
cles on  the  outer  and  posterior  aspects  of  the  hip  and  in  the  cellular  tissue 
about  the  great  sciatic  nerve.  There  was  no  laceration  of  muscular  tissue. 
The  substance  of  the  adductor  magnus  and  the  lower  border  of  the  ob- 
turator externus  were  much  ecchymosed.  A  large  rent  was  found  in  the 
capsule  on  the  inner  aspect,  extending  from  the  ilio-pubic  eminence  to  the 
upper  border  of  the  obturator  externus  muscle.  The  capsule  teas  torn  from 
its  pelvic  attachment.  The  ligamentum  teres  was  torn  from  the  head  and  lay 
loose  in  the  socket.  The  head  could  easily  be  redislocated  upon  the  edge 
of  the  obturator  foramen ;  and  when  this  was  done  it  pushed  the  obturator 
externus  before  it,  rendering  it  tense  and  bulging. — Curling,  Med.  Times, 
vol.  vii.  N.  S.,  p.  422. 

Remarks.  This  was  a  dislocation  inward.  Note  two  points  :  1. 
There  were  no  muscles  torn,  2.  The  rent  in  the  capsule  was  at  its 
periphery,  and  from  the  socket.  Such  a  rent  would  favor  reduction, 
which  took  place  while  the  patient  was  being  gently  handled  by  the 
nurses. 


PATHOLOGY.  67 

Case  VII. — Dorsal  dislocation.  Young  man,  fatally  injured  by  a  fall  from 
a  second  story.  Death  in  twenty-four  hours.  On  dissection  a  large  amount 
of  coagulated  blood  was  found  beneath  the  gluteus  maximus  ;  the  pyriformis, 
gemelli,  obturator  internus,  quadratus  femoris,  and  obturator  externus  were 
completely  ruptured.  The  capsule  was  torn  inferiorly  and  posteriorly;  it 
was  intact  at  the  superior  and  internal  part.  The  ligamentum  teres  was 
torn  from  the  head.  The  head  lay  posteriorly  upon  the  gluteus  medius. 
Some  fibres  of  the  pectineus  were  torn. — Charles  H.  Todd,  Cooper  on 
Fractures  ayid  Dislocations,  Case  40, 

Remarks.  There  is  no  mention  of  injury  to  the  nerve;  and  we 
may  infer  that  it  escaped.  As  the  capsule  was  not  torn  internally, 
the  quadratus  and  obturator  externus  were  not  torn  by  direct  contact 
with  the  head.  The  position  of  the  limb,  at  the  instant  of  rupture 
of  the  capsule,  was  probably  that  of  flexion  and  hyper-adduction, 
with  rotation  inward.  The  two  muscles  mentioned  above  were  torn 
by  hyper-tension.  The  hemorrhage  and  the  traumatism  to  the  other 
muscles  were  probably  due  to  direct  contact.  The  pectineus  was 
torn  by  overstretching. 

Case  VIII. — Male,  nineteen  years  old,  strong  and  healthy,  admitted  to 
Edinburgh  Royal  Infirmary.  Railroad  injury.  Death  in  a  few  hours.  Thy- 
roid dislocation  of  left  femur.  On  dissection,  fourteen  hours  after  death, 
there  was  found  an  extensive  extravasation  of  blood  and  many  muscles  torn 
and  bruised.  The  obturator  internus  was  partly  torn,  and  some  of  its  sub- 
stance had  been  forced  into  the  socket.  Its  tendon  was  not  ruptured.  The 
head  had  been  reduced.  The  capsular  rent  was  on  the  inner  and  lower 
aspect.  The  ligamentum  teres,  with  a  thin  scale  of  bone  attached,  had 
been  torn  from  the  pit  in  the  head. — Thomas  Anxandale,  British  Medical 
Journal,  1870,  p.  101. 

Remarks.  The  dislocation  was  inward,  and  I  infer  that  it  was  a 
clerical  error  to  state  that  some  of  the  fibres  of  the  obturator  internus 
were  driven  into  the  socket.  It  is  more  probable  that  the  muscle 
referred  to  was  the  obturator  externus.  Two  points  are  worthy  of 
emphasis:  1.  Some  muscular  material  was  forced  into  the  socket. 
This  is  a  fact,  not  a  theory.  2.  The  teres  was  not  torn  from  the 
head ;  it  w^as  peeled  off  from  it  with  a  scale  of  bone.  Hence,  if  it 
had  been  ten  times  as  strong,  its  greater  strength  would  have  availed 
nothing  against  luxation. 

Case  IX. — Thyroid  dislocation.  Young  man,  killed  by  a  fall  from  a 
window.  Hip  symptoms:  Great  trochanter  less  prominent  than  natural, 
with  an  unusual  fulness  in  the  groin.     Adduction  of  the  thigh  resisted; 


68 


INTR  OD  UCTOR  Y  STUD  Y. 


abduction  easy.  No  marked  eversion  on  dissection  ;  the  great  sacro-sciatic 
nerve  was  found  to  be  ecchymosed  and  bruised ;  the  gracilis  was  torn 
through ;  the  abductor  longus  and  brevis  were  partly  torn;  the  capsule  was 
extremely  torn  on  the  inner  side;  the  ligamentum  teres  was  ruptured. — 
Shaw,  Medical  Times,  vol.  xvii.  N.  S.,  p.  459. 

Remarks.  In  this  case  the  head  was  dislocated  internally ;  but 
it  could  not  have  touched  the  gracilis  nor  the  adductor  longus.  How, 
then,  were  they  torn  ?  The  explanation  is  simple.  If  we  accept 
the  lesson  of  the  dissecting-room,  that  internal  dislocations  are  by 
abduction,  we  see  that  on  abduction  to  a  point  necessary  to  dislocate, 
these  muscles  were  put  upon  a  severe  strain,  and  the  rupture  was 
due,  not  to  contact  with  the  head,  but  to  overstretching.  On  the 
same  theory  of  overstretching  the  ecchymosis  of  the  nerve  may  be 
explained. 

Case  X. — A  maniac  jumped  from  a  third-story  window,  receiving  in- 
juries that  proved  fatal  in  three  hours.  Thigh  injured.  Symptoms:  Short- 
ening and  inversion  ;  shaft  crossed  the  symphysis  pubis,  and  was  immovably 
fixed  in  that  position.  On  dissection,  twelve  hours  after  death,  the  gluteus 
medius  and  minimus  were  found  ruptured  at  their  posterior  edges ;    the 

Fig.  55. 


pyriformis  and  the  gemelli  were  partly  torn,  but  the  four  portions  of  the 
tendon  of  the  obturator  internus  which  pass  through  the  lesser  sciatic 
notch  were  drawn  out  and  separated  from  their  connection  with  the  muscular 
fibres.    The  head  of  the  femur  presented  through  a  rent  in  the  capsule 


PATHOLOGY.  69 

opposite  the  upper  part  of  the  tuber  ischii  above  the  quadratus,  so  that  the 
great  sciatic  nerve  was  somewhat  displaced  and  pressed  against  the  tuber 
ischii. — Thomas  Wormald,  London  Medical  Gazette,  vol.  xix. 

Remaeks.  Bigelow  lays  great  stress  upon  the  anatomical  struc- 
ture of  the  obturator  internus.  He  calls  especial  attention  to  the 
separate  fibres  that  make  up  its  tendon,  and  assigns  to  this  muscle 
the  province  of  arresting  the  head  in  its  upward  march.  He  has  a 
distinct  class  of  dislocations  which  he  calls  "  dorsal  below  the  ten- 
don." Now,  before  dissection,  one  would  have  assigned  this  disloca- 
tion to  that  variety,  since  the  head  lay  below  the  sciatic  notch,  and 
the  limb  crossed  its  fellow  at  a  high  point.  But,  on  dissection,  the 
obturator  internus  was  found  hanging  in  shreds  from  the  trochanter, 
and  incapable  of  offering  the  least  resistance  to  the  upward  progress 
of  the  head. 

This  case  confirms  in  a  striking  manner  a  result  which  I  have 
stated  (p.  79),  that  in  dislocations  the  tendon  never  gives  way — it 
tears  from  its  insertion  or  from  the  muscle.  This  is  easily  explained 
in  experimental  work,  in  which  the  bone,  capsule,  tendon,  and  fibrous 
structure  may  undergo  no  change,  while  the  muscular  fibre  has  lost 
its  toughness.  This  case,  due  to  traumatism,  proves  the  truth  of  the 
assertion.  In  experimental  work  I  have  drawn  the  tendons  out  of 
the  muscular  part  precisely  as  described  above. 

Case  XI. — Robert  S.,  forty-five  years  old,  was  knocked  down  and  injured 
while  coupling  railroad  cars.  He  was  unable  to  rise,  and  soon  after  was 
taken  to  the  Leicester  Infirmary  and  placed  under  the  care  of  Mr.  Marriott. 
Dislocation  backward  of  right  femur,  with  less  advancement  of  the  knee 
and  inversion  of  the  foot  than  usual.  No  efforts  at  reduction,  owing 
to  collapse.  Death  occurred  on  the  following  day.  On  dissection,  the 
head  of  the  femur  was  found  immediately  behind  the  acetabulum,  having 
escaped  below  the  pyriformis.  No  laceration  of  muscular  fibre  was  any- 
where detected.  On  manipulation,  the  muscles  were  found  to  be  the  main 
obstacle  to  reduction.  The  ligamentum  teres  was  torn  from  the  head.  The 
capsule  was  freely  torn  all  round,  only  a  small  portion  remaining  attached 
to  the  femur  in  front  and  behind.  The  cotyloid  ligament  and  the  cartilages 
were  uninjured. — Samuel  Lee,  St.  George's  Hosp.  Rep.,  1872-4,  vols,  v.-vii. 

Remarks.  If  the  dislocation  was  below  the  pyriformis,  the  head 
must  have  been  between  it  and  the  obturator  internus,  as  it  is  dis- 
tinctly said  there  was  no  muscular  lesion.  It  is  impossible  to  repro- 
duce this  injury  upon  the  cadav'er,  owing  to  the  brittle  condition  of 
the  muscles.     It  is  this  condition  of  head  in  chaneery  that  leads  me 


70 


INTRODUCTORY  STUDY. 


to  classify  it  among  the  real  obstacles  to  reduction  from  the  usual 
methods. 

Case  XII. — Stephen  H.,  seventy  years  old,  foundry  laborer,  crushed  by 
a  heavy  weight  so  severely  as  to  drive  a  large  quantity  of  intestines  through 
a  rent  in  the  scrotum.  Death  from  peritonitis  on  the  eighth  day.  Symp- 
toms :  Left  hip  inverted  ;  thigh  flexed  and  rigid ;  knee  rested  above  patella 
of  sound  side ;  the  head  of  the  femur  could  with  difiiculty  be  located  near 

Fig.  56. 


the  sciatic  notch ;  trochanter  a  little  posterior  to  normal  situation.  On 
dissection,  the  head  was  found  to  be  dislocated  almost  directlj  backward, 
resting  behind  the  acetabular  ridge,  opposite  the  middle  and  upper  half  of 
the  great  sciatic  foramen.  The  pyriformis  was  stretched  above  the  head. 
The  gemellus  superior  was  ruptured,  and  the  obturator  internus  was  intact. 
— Wm.  MacCormac,  St.  Thomas's  Hasp.  Rep.,  1871. 

Remarks.  The  fracture  of  the  pelvis  and  the  expulsion  of  the 
intestines  through  a  rent  in  the  scrotum  may  be  reasonably  explained 
on  the  theory  of  hyper-flexion;  and  this,  Avith  slight  rotation  inward, 
would  effect  dislocation  outward. 


PATHOLOGY.  71 

Altered  Relation  of  Parts  After  Dislocation. 

Before  Reduction.  So  long  as  the  head  remains  out  of  the 
socket  all  the  structures  that  attach  to  the  great  and  small  tro- 
chanters will  be  aifected,  some  being  stretched  and  others  relaxed. 
If  the  head  be  dislocated  inward,  the  great  trochanter  will  approach 
the  socket,  and  may  lie  in  it  to  a  variable  degree.  When  the  knee 
is  abducted  and  the  thigh  flexed,  the  trochanter  tends  to  sink  down 
into  the  socket.  The  tendon  of  the  gluteus  minimus  will  follow 
the  trochanter  inward,  and,  with  the  tendons  of  the  piriformis  and 
obturator  internus  (if  untorn),  will  lie  upon  the  outer  edge  of  the 
acetabulum  or  be  stretched  partly  over  it.  Usually  the  part  of  the 
capsule  that  remains  untorn  is  that  which  is  covered  by  and  adher- 
ent to  the  tendons  of  the  ilio-psoas  and  gluteus  minimus,  and  in 
those  cases  where  the  capsule  is  actually  torn  beneath  these  ten- 
dons the  torn  parts  of  the  capsule  will  retain  their  attachments  to 
the  overlying  muscles.  Both  these  muscles  escape,  as  a  rule.  I 
have  never  seen  in  experimental  or  pathological  investigation  any 
injury  to  the  psoas,  but  the  gluteus  minimus  and  medius  are  reported 
as  utterly  destroyed.     (See  Cases  IV.  and  V.) 

While  dislocation  persists  the  edges  of  the  capsule  are  held  apart, 
being  separated  to  the  extent  of  the  full  width  of  the  neck  of  the 
femur.  Certain  writers  have  permitted  their  imaginations  to  guide 
their  pens,  and  have  stated  that  rapid  healing  of  the  capsule  with  its 
consequent  shutting  oif  of  the  socket  is  one  of  the  insurmountable 
obstacles  to  reduction.  I  cannot  indorse  such  a  sentiment,  and  be- 
lieve that  a  persistent  passage  to  the  socket  is  not  an  infrequent 
condition,  or  that,  if  adhesions  take  place,  they  are  easily  broken  up. 

If  the  dislocation  be  outward,  the  remnant  of  untorn  capsule  and 
the  tendon  of  the  psoas  will  be  drawn  across  the  socket  and  rest 
upon  its  outer  rim.  It  is  difficult  to  understand  how  any  adhesions 
of  the  capsule  to  the  cartilaginous  rim  of  the  socket  (both  lined  by 
epithelium)  could  take  place,  or  how,  if  they  did  occur,  they  could 
be  formidable.  Such  adhesions  would  shorten  the  remnants  of  the 
capsule  and  must  readily  yield  to  manipulation.  I  am  firmly  of  the 
belief  that  capsular  adhesion  (the  so-called  shutting  off  of  the  socket) 
in  cases  of  unrestored  dislocations  is  little  w^orthy  of  serious  consid- 
eration, and  should  be  given  a  much  less  prominent  position  in  the 
category  of  obstacles. 


72  INTRODUCTORY  STUDY. 

Conditions  of  the  Head  and  Socket.  The  head  and  socket 
may  remain  unaltered  for  years,  or  they  may  undergo  rapid  inflam- 
matory and  other  changes.  Something  can  be  inferred  from  the 
history  of  a  case.  If  the  dislocation  has  been  effected  by  simple 
leverage  {i.  e.,  if  the  head  has  been  lifted  out  of  the  socket),  the  car- 
tilages of  the  head  and  the  socket  escape  without  bruising.  Such 
dislocations,  taking  place  in  adult  life,  will  not  be  followed  by  rapid 
shrinking  of  the  head  or  socket.  Cases  are  reported  in  Avhich  the 
cartilages  of  the  head  and  socket  have  been  found  smooth  and  glis- 
tening years  after  a  dislocation  has  taken  place.  Bernard  E.  Brod- 
hurst  found  the  cotyloid  cavity  to  retain  its  full  depth  three  years 
after  dislocation  of  the  head  of  the  femur.  Fourier  has  placed  a 
dissection  upon  record  in  Avhich,  after  thirteen  years  of  unrestored 
dislocation,  the  socket  preserved  its  size,  form,  and  depth  (St. 
George's  Hosp.  Rep.,  1868,  vol.  iii.     Bigeloiv,  p.  108). 

In  cases  like  those  just  described  (i.  e.,  in  the  class  in  which  the 
cartilages  were  not  bruised)  a  new  socket  is  formed  and  a  new  cap- 
sule is  created.  The  socket  is  formed  by  a  thinning  of  the  under- 
lying bone,  and  probably  by  increased  physiological  activity  at  its 
margins.  There  is  little  known  about  such  capsular  attachments ; 
but  there  is  no  reason  why  the  new  capsule  should  not  communicate 
persistently  with  the  old  socket,  as  is  the  case  with  congenital  dislo- 
cations. 

Dislocations  occurring  before  puberty  must,  if  unrestored,  lead  to 
atrophy  of  all  the  constituents  of  the  joints. 

When  dislocations  are  the  result  of  direct  violence  (as  when  a 
person,  half-stooping,  receives  a  crushing  blow  from  a  caving  em- 
bankment, or  when  one  falls  a  distance,  striking  heavily  upon  the 
knee)  the  concussion  to  the  articular  cartilages  is  likely  to  be  followed 
by  inflammatory  changes.  If  the  head  is  not  promptly  restored, 
such  inflammation  would  produce  direct  adhesion  between  the  head 
and  surrounding  parts,  and  be  followed — not  by  a  new  socket,  but 
by  ankylosis.  If,  however,  the  head,  under  these  circumstances,  be 
promptly  reduced,  the  result  will  probably  be  synovitis  with  anky- 
losis. In  one  of  my  cases  of  unreduced  dislocation  inward  into  the 
thyroid  depression,  due  to  earth  falling  upon  the  man,  the  resulting 
inflammation  and  adhesions  between  the  head  and  the  subjacent 
parts  were  so  intimate  that  a  disturbance  of  the  relations,  in  an  effort 
to  restore  the  part,  gave  rise  to  a  distinct  sense  of  crepitus,  and  at 


AIDS  AND  OBSTACLES  TO  REDUCTION.  73 

the  autopsy  it  was  found  that  the  head  was  bare  of"  cartilage  and  of 
the  outer  shell  of  bone,  which  had  remained  adherent  to  the  floor  of 
the  new  bed. 

If,  in  such  a  case,  reduction  is  accomplished,  ankylosis  must  ensue, 
and  the  only  gain  would  be  a  better  position  of  the  limb. 

Osteophytes.  The  growth  of  new  bone,  as  a  sequence  of  dislo- 
cations, is  worthy  of  consideration.  When  the  rent  in  the  capsule 
is  between  its  acetabular  and  femoral  attachments  the  periosteum  is 
not  disturbed,  and,  unless  a  fracture  be  present,  no  bone  repair  will 
be  needed.  Two  possibilities,  however,  present  themselves.  Should 
the  capsule  with  periosteum  be  torn  from  the  rim  osteophytes  might 
oppose  an  obstacle  to  reduction,  if  this  be  long  delayed ;  or,  if  the 
head  be  promptly  restored,  osteophytes,  springing  up  around  the 
border  of  the  socket,  would  greatly  abridge,  if  not  abolish,  motion. 
Should  the  capsule  be  torn  from  the  neck,  the  osteophytes  would 
probably  be  less  formidable,  though  new  bone  will  grow,  not  only  at 
the  points  of  denuded  bone,  but  also  at  the  detached  border  of  the 
capsule,  which  may  be  covered  with  periosteum. 

Changes  in  the  Socket  and  Head  After  Reduction. 

These  changes  I  shall  not  discuss.  Those  that  have  been  noticed 
are :  Synovitis  due  to  traumatism,  with  all  the  symptoms  of  rapid 
inflammatory  action ;  subacute  symptoms,  followed  by  disuse  and 
atrophy,  possibly  due  to  turning  in  of  the  capsule  or  to  a  foreign 
body  in  the  socket,  such  as  muscle  or  blood.  Fibrous  or  bony  anky- 
losis is  likely  to  follow  under  such  circumstances. 

AIDS  AND  OBSTACLES  TO  REDUCTION. 

Anaesthetics  have  swept  away  every  device  that  surgical  ingenuity 
has  brought  forward  for  the  reduction  of  dislocations.  Not  a  single 
one  remains  in  shop  or  hospital,  and  only  in  works  on  general  sur- 
gery can  one  still  find  the  long  catalogue  of  obsolete  contrivances, 
not  one  of  which  was  constructed  upon  the  true  pathology  of  dislo- 
cations. 

The  reduction  of  a  dislocation  is  far  from  being  a  simple  thing, 
and  no  one  who  truly  estimates  the  condition  of  his  patient  will 
regard  it  as  such. 


74  INTROD  UCTOR  Y  STUD  Y. 

As  a  preliminary  measure,  therefore,  and  before  the  limb  is 
touched,  I  earnestly  recommend  fixation.  The  fixation  of  the  pelvis 
will  be  seen  to  be  of  the  utmost  importance,  if  we  take  into  consid- 


eration its  shape.  Had  Nature  given  the  pelvis  a  broad,  flat  dorsal 
surface,  reduction  would  have  been  easier ;  but  dislocations  would  be 
more  frequent.  In  giving  to  man  a  narrow  dorso-sacral  support, 
Nature  has  thrown  safeguards  around  the  articulation,  for  the  rocking 
and  tilting  pelvis  readily  accommodates  itself  to  motion  from  the 
thighs,  and  thus  circumvents  many  a  vicious  attack. 


Fig.  5S. 


With  the  tliigli  bone  dislocated,  all  efforts  at  its  reduction  are 
applied  through  the  thigh  itself,  or  through  the  bent  leg,  and  always 
at  the  outer  angle  of  the  pelvis.     Thus  the  femur,  which  we  are 


AIDS  AND  OBSTACLES  TO  REDUCTION. 


75 


attempting  to  restore,  becomes  the  direct  agent  or  lever  in  moving 
the  pelvis,  and  contributes  to  our  defeat.  The  chief  advantages  of 
rotation  and  circumduction  as  methods  of  reduction  are  that  they  do 
not  communicate  to  the  pelvis  their  motion  in  the  same  degree  that 
other  methods  do.  But  it  is  not  difficult  to  show  that  reduction  by 
circumduction  is  both  unscientific  and  dangerous. 

A  method  of  fixation  that  I  have  often  advantageously  adopted, 
but  whose  only  excellence  is  its  simplicity,  consists  of  three  opened 
screw-eyes  and  a  long  and  strong  bandage.  (In  the  shops  the  screw- 
eyes  are  screw-rings,  but  they  can  be  readily  opened.)  I  screw  one 
at  the  junction  of  the  thighs  in  the  perineum,  and  one  at  the  iliac 
flanges.  (Fig.  60.)  The  prominences  of  the  ilium  and  pubes  are 
protected  with  folded  towels. 


Fig.  59. 


Fig.  60. 


Whether  the  operator  fixes  the  pelvis  or  not,  he  will  find  a  large, 
heavy,  muscular  thigh  a  very  inconvenient  thing  to  handle.  After  he 
has  flexed  the  thigh  to  a  perpendicular  he  can  readily  grasp  the  ankle, 
but  he  cannot  grasp  the  knee.  Many  do  not  attempt  to  grasp  the 
knee,  but,  placing  the  hand  upon  it,  steady  it  or  circumduct  it,  while 
the  other  hand  guides  the  ankle.  Now,  though  this  procedure  is 
frequently  successful,  it  is  not  without  danger.  Pressure  upon  the 
knee  drives  the  head,  in  rotation  and  circumduction,  more  irresist- 
ibly against  any  obstacle  within  reach,  and  in  my  presence  it  once 
hooked  up  the  sciatic  nerve.     It  is  much  more  scientific  (for  it  is 


76 


INTR OD  UCl  OR  Y  STUD  Y. 


reversing  the  steps  of  a  dislocation)  to  lift  the  thigh  in  the  direction 
of  its  long  axis.  This  can  be  done  by  placing  the  bent  elbow  be- 
neath the  bent  knee,  though  this  is  often  done  at  great  disadvantage 
and  is  tiresome.  To  enable  me  to  use  my  strength  advantageously, 
but  not  to  increase  it,  I  have  often  found  the  apparatus  depicted  in 
Fis:.  61  of  service. 


Fig.  61. 


/I 


•^ 


if        ■ 


11/ 


11/ 


The  instrument  is  first  thrown  into  a  bucket  of  water  to  soften  the  sole-leather,  and  after 
the  two  halves  have  been  secured  to  the  part  by  bandage  the  traction  bars  A  are  adjusted 
and  also  secured  by  bandage.    Finally  the  adjustable  handle  C  is  put  in  place. 


The  Shape  of  the  Femur  and  the  Effect  of  Traction  and 
Manipulation.  In  handling  the  femur  we  must  bear  in  mind 
three  things :  1,  that  it  is  not  a  straight  bone ;  2,  that  after  dis- 
location it  does  not  revolve  about  the  head  as  a  centre,  but  upon  the 
axis  of  the  shaft ;  3,  that  after  dislocation  the  head  is  outside  the 
limits  of  the  capsule,  and  that  the  remnant  of  untorn  capsule  ex- 
tends between  the  upper  part  of  the  socket  and  the  front  part  of  the 
base  of  the  neck  of  the  femur.  If  the  femur  were  a  straight  bone, 
traction  in  any  direction  Avould  bring  the  head  into  line  with  the 
socket  after  dislocation.  The  different  effects  of  traction  upon  the 
normal  and  dislocated  head  should  be  understood.  If  the  head  be 
in  its  socket   and   the  femur  be   flexed   to  a  right  angle,  traction 


AIDS  AND  OBSTACLES  TO  REDUCTION. 


77 


upward  (Fig.  62)  will  not  be  resisted  by  the  capsule,  for  this  is  now 
relaxed.  The  resistance  comes  from  atmospheric  pressure — not  from 
a  taut  capsule.  In  such  a  case  the  line  of  traction  does  not  follow 
the  shaft,  but  runs  from  the  knee  through  the  socket  (dotted  line, 
Fig.  62).  But  the  instant  the  head  escapes  from  the  socket  suction 
has  nothing  more  to  do  with  it,  and  as  the  head  is  free  from  all 
attachments  traction  upward  will  be  resisted  by  the  remnant  of 
untorn  capsule  and  bring  the  shaft  (not  the  head)  in  line  with  the 
socket.  If  the  head  be  dislocated  inward,  upward  traction  will  bring 
the  great  trochanter  over  the  socket.    (Fig.  63.)     Under  such  cir- 


FlG.  62. 


Fig.  63. 


Fig.  64. 


cumstances  it  is  folly  to  put  forth  great  force  in  a  direction  perpen- 
dicular to  the  pelvis  with  a  view  to  draw  the  head  over  the  socket, 
for  the  greater  the  upward  force  the  greater  the  difficulty  in  the  way 
of  the  head  approaching  the  socket. 

The  same  principle  is  involved  in  dislocations  outward.  Traction 
upward  (?'.  e.,  vertically,  with  the  body  horizontal)  brings  the  head 
against  the  outer  rim  of  the  socket.  The  head  must  now  go  out- 
ward (Fig.  64)  before  it  can  get  into  the  socket.  The  instant  it  is 
forced  outward  the  remnant  of  capsule  tightens,  and  the  head  is 
blocked  just  at  the  moment  when  it  should  overstep  the  rim.  Under 
these  circumstances  the  thigh  should  be  adducted,  or  the  head 
rotated  away  from  the  projecting  rim  of  the  socket,  when  the 
obstacle  to  reduction  mav  vanish. 


78 


IXTROn  UCTOB  Y  STUB  Y. 


The  Crook  in  the  Neck  of  the  Femur  becomes  an  Obsta- 
cle in  Rotation,  Rotation  winds  up  and  of  course  shortens  the 
capsule.  This  obviously  brings  the  base  of  the  shaft  (i.  e.,  the  great 
trochanter,  not  the  head)  nearer  to  the  socket,  and  when  the  opera- 
tor hopes  to  turn  the  head  into  the  socket  the  head  or  neck  strikes 
the  border  of  the  now  tense  and  shortened  capsule  and  is  thus 
prevented  from  entering  the  socket.  Attention  is  directed  to  these 
obstacles  to  reduction,  because,  as  such,  they  are  created  by  the  ill- 
directed  efforts  of  the  manipulator,  and  will  all  vanish  under  a  proper 
change  in  procedure. 

The  Rent  in  the  Capsule.  I  have  elsewhere  discussed  the  im- 
probability of  a  slit  in  the  capsule  ever  occurring  and  thus  becoming 


Fig.  65. 


Fig.  66. 


an  obstacle  to  reduction  ;  but  while  the  head  cannot  escape  through 
a  slit  (since  the  smallest  diameter  of  the  orifice  of  exit  must  be,  at 
the  instant  of  escape,  equal  to  the  diameter  of  the  head),  yet  even 
under  these  circumstances  I  have  seen  the  neck  of  the  femur  so 
cauf^ht  by  the  borders  of  the  rent  as  that  this  constituted  a  decided 
obstacle  to  reduction.  As  soon  as  the  head  escapes  new  relations 
between  the  orifice  of  exit  and  the  head  are  created.  For  an  in- 
stant, while  the  head  is  escaping,  the  sides  of  the  rent  (Fig.  65)  may 
bulcre ;  but  the  moment  the  head  escapes  and  traction  takes  place 
between  the  borders  of  the  untorn  portion  the  orifice  of  exit  may  be 
narrowed,  as  in  Fig.  Q6.  Obviously  the  head  cannot  be  returned, 
except  that  it  be  presented  under  circumstances  similar  to  those 


AIDS  AND  OBSTACLES  TO  REDUCTION.  79 

present  at  the  moment  of  exit,  as  in  Fig  65.  I  have  demonstrated 
this  repeatedly  in  experimental  work,  restoring  a  dislocation  with 
ease  in  one  position  and  by  one  method,  that  became  impossible 
under  changed  relations. 

The  Rotator  Muscles  as  Obstructors.  The  obstruction  may 
arise  from  either  of  two  conditions  :  The  short  muscle  may  not  be 
torn,  and  thus  obstruct  the  way,  or  it  may  be  torn  and  its  detached 
portion  be  pushed  into  the  socket  in  advance  of  the  head.  As  a 
rule,  if  we  may  be  guided  by  pathology  and  experimental  work,  one 
or  more  of  the  short  muscles  will  be  torn.  When  I  have  attempted 
to  dislocate  upward  and  outward,  by  flexion,  adduction,  and  rotation 
inward,  I  have  torn  the  obturator  internus  before  rupturing  the 
capsule. 

The  point  of  lesion  in  the  three  short  rotators  is  worthy  of  note. 
I  have  never  torn  the  tendon  from  its  bony  attachment  or  ruptured  it, 
but  the  tendon  may  be  torn  from  its  insertion  into  the  muscle  (Case  X., 
p.  68),  or  the  muscle  may  be  torn  in  its  fleshy  part  or  from  its  origin. 
Hence  there  will  be  two  parts  of  the  muscle  to  consider  after  the 
lesion — viz.,  the  part  attached  through  tendon  to  the  base  of  the 
neck  and  the  part  attached  to  the  pelvis.  The  first  part — viz.,  the 
part  attached  through  tendon  to  the  base  of  the  neck — will  follow  the 
femur,  that  is,  will  be  dragged  after  it.  In  one  of  my  experiments, 
after  a  reduction,  I  found  the  tendons  (with  considerable  attached 
muscle)  of  the  three  short  rotator  muscles  caught  over  the  neck  of 
the  femur,  precisely  as  the  nerve  is  caught  up  sometimes.  In  this 
case  I  had  made  an  everted  dorsal  from  a  regular  dorsal  disloca- 
tion ;  and,  in  restoring  the  head,  the  three  torn  muscles,  dangling 
from  the  neck  through  their  attached  tendons,  were  caught  up  and, 
after  reduction,  lay  across  the  neck  beneath  the  untorn  remnant  of 
the  capsule.  Their  presence  could  not  have  been  predicated  from 
any  deformity  or  restriction  of  motion.  The  second  part — viz.,  the 
part  attached  to  the  pelvis — will  not  follow  the  movements  of  the 
femur,  but  will  be  passive.  It  may,  however,  if  it  lie  in  front  of  the 
head,  be  pushed  into  the  socket.  From  experimental  work  I  am 
strongly  of  the  opinion  that  no  part  of  the  pyriformis  or  obturator 
internus  can  be  pushed  into  the  socket,  for  the  simple  reason  that 
the  fragment  will  be  too  short  to  reach  it.  Not  so  with  the  muscle 
that  lies  internal  to  the  socket — viz.,  the  obturator  externus.  I  have 
repeatedly  found  the  body  of  this  muscle,  lying  like  a  dead,  inert 


80  INTRODUCTORY  STUDY. 

mass,  at  the  door  of  the  socket,  unable  to  pull  itself  out  of  the  way 
or  to  resist  the  pressure  from  the  head,  and  hence  forced  into  the 
socket.  So  much  for  dead  muscle.  Whether  in  the  living  the 
stimulus  of  pain,  from  the  pressure  of  the  head,  would  excite  con- 
traction and  thus  clear  the  way  is  a  matter  of  pure  speculation. 
Under  the  head  of  "  Pathology  "  (Case  VIII.,  p.  67),  in  the  history 
of  one  of  the  cases,  it  is  stated  that  the  obturator  internus  was  pushed 
into  the  socket.  I  take  this  to  have  been  a  clerical  error.  The  evi- 
dence of  muscular  structure  driven  before  the  head  into  the  socket 
is  incomplete  extension.  This  matter  will  be  taken  up  again  in  the 
chapter  on  "  Cleaning  Out  the  Socket." 

The  Sciatic  Nerve.  This,  as  an  obstruction,  has  not  received 
the  attention  to  which  it  is  entitled.  In  the  reports  of  cases  I  have 
seen  allusion  to  some  unknown  obstacle,  the  description  of  which 
agrees  fully  with  what  I  have  witnessed  in  experimental  work.  In 
reducinor  a  dorsal  luxation  bv  rotation  outward,  I  have  seen  the 
head  strike  squarely  against  the  sciatic  nerv^e  and  flatten  it  out, 
being  thus  debarred  from  entrance  to  the  socket.  In  other  cases 
the  head  would  catch  upon  the  nerve  which  would  first  resist  it, 
then,  slipping  suddenly  off,  permit  it  to  enter  the  socket,  giving 
the  impression  that  a  tendon  or  portion  of  the  capsule  had  given 
way.  This  has  happened  so  frequently  that  I  feel  persuaded  that 
many  surgeons  have  felt  the  arrest  from  and  sudden  disengagement 
through  letting  go  of  the  nerve  in  the  circumductive  sweep  of  Reid 
and  Bigelow. 

STEPS  OF   DISLOCATIONS. 

In  the  early  part  of  this  work  I  have  endeavored  to  show  that  the 
mechanism  of  dislocations  demanded  a  fulcrum  as  well  as  a  lever, 
and  have  pointed  out  the  positions  and  movements  through  which  a 
fulcrum  could  be  obtained.  I  wish  now  to  analyze  the  steps  of  a 
dislocation. 

This  is  an  important  subject,  for  no  one  can  make  a  dislocated 
head  retrace  its  steps  unless  he  knows  and  fully  understands  the 
steps  of  the  dislocation. 

Dislocation  inward  presents  by  far  the  simplest  mechanism.  Its 
three  steps  or  stages  are  : 

1.  The  rupture  of  the  capsular  ligament ; 


STEPS  OF  DISLOCATIONS. 


81 


2.  The  escape  of  the  head  beyond  the  limits  of  the  socket ; 

3.  The  shiftings  that  follow  in  the  dislocated  head. 

1,  Rupture  of  the  Capsule.  This  is,  of  course,  the  initial  lesion, 
without  which  a  traumatic  dislocation  cannot  occur ;  but  before  the 
capsule  yields  in  all  dislocations  dependent  upon  a  bony  fulcrum  the 
head  must  rise  out  of  the  bed  of  the  socket  (Fig.  67)  and  attack  the 
capsule,  i.  e.,  the  dislocating  force  must  act  from  within  outward ; 
for  in  no  other  way  can  the  capsule  be  ruptured.  The  head  rises  as 
the  distal  end  of  the  shaft  descends,  and  rises,  like  the  short  end  of 
any  lever,  upon  its  fulcrum.  By  its  action  the  head  tends  to  move 
away  from  the  further  rim  of  the  socket,  and  to  bring  its  greatest 
force  upon  the  capsule  at  a  point  midway  between  the  attachments. 
Thus  the  capsule  is  ruptured. 

Fig.  67. 


savy  ri/icftun 

riPP£D  WITH  CARTILAGE. 


2.  Escape  of  the  Head  beyond  the  Boundaries  of  the  Socket. 
This  would  seem  the  natural  sequence  of  rupture  of  the  capsule ; 
but  it  is  not.  The  capsule  may  be  fully  ruptured  by  hyper-abduction 
without  the  neck  shifting  its  position  upon  the  fulcrum.  In  experi- 
mental work  I  have  seen  the  fibres  yield,  as  it  were,  one  by  one,  and 
after  the  head  had  emerged  through  the  rent  in  the  capsule,  it 
remained  directly  over  the  socket,  and  all  that  was  necessary  to 
restore  it  was  to  raise  the  knee.  In  this  class  of  cases,  I  repeat,  the 
relations  of  the  lever  to  the  fulcrum  are  not  disturbed,  and  often  the 
slightest  motion,  such  as  lifting  a  person  into  a  carriage  or  placing 
him  in  bed,  is  sufficient  to  effect  a  restoration  (Case  VI.,  Pathology 
p.  66).     In  this  class  of  cases  the  luxation  is  probably  the  result  of 

6 


82  INTBOD UCTOB Y  STUD  Y. 

force  exerted  slowly.  When,  in  experimental  work,  I  have  found 
such  a  condition  present,  I  have  been  obliged  to  resort  to  a  second 
and  independent  force,  to  get  the  head  bej^ond  the  region  of  the 
socket,  viz.,  to  rotate  outw^ard,  in  order  to  lift  the  great  trochanter 
over  the  brim  of  the  socket,  and  then  either  bring  the  limb  down  in 
extension  or  push  it  inward,  to  get  the  head  beyond  the  socket  and 
into  the  thyroid  depression. 

But  the  fibres  of  the  capsule  do  not  always  tear  gradually,  i.  e., 
one  by  one.  They  may  all  resist  until  the  instant  of  maximum 
violence,  and  all  snap  at  once,  freeing  the  head  suddenly ;  and  in  an 
instant  later  it  is  found  beyond  the  boundaries  of  the  socket. 

Now,  let  us  analyze  the  process.  The  long,  strong  lever  carried 
outward,  constitutes  the  primary  force  ;  the  bony  rim  is  the  fulcrum, 
and  the  strong  capsule  offers  the  resistance.  Note  especially  that 
the  bony  resisting  fulcrum  is  covered  by  an  elastic  cartilage,  viz., 
the  peripheral  cotyloid  ligament,  and  that  this  cartilaginous  covering 
of  the  fulcrum  is  compressible.  (Fig.  67.)  Hence,  as  the  lever  is 
being  carried  outward  the  cartilage  is  becoming  more  and  more  com- 
pressed, thus  creating  a  secondary  force,  while  the  capsule  that  can- 
not readily  stretch  is  fast  reaching  its  limit  of  resistance.  Suddenly 
the  capsule  snaps  with  a  loud  report,  the  compressed  peripheral  car- 
tilage recoils  upon  the  neck  which  Avas  pressing  it  down,  and  the 
head,  freed  by  the  rupture  of  the  capsule,  is  propelled  as  from  a 
gun,  upward  and  inward,  and  lands  clear  beyond  the  confines  of  the 
socket. 

Fig.  68. 


The  reader  can  satisfy  himself  on  this  point  by  means  of  a  very 
simple  experiment.  Let  him  take  a  lever  {AC,  Fig.  08),  tie  the  point 
G  down  with  a  string  and  place  a  hard  fulcrum  at  B.  If  power  is 
exerted  at  A,  it  will  break  the  string  without  disturbing  the  relations 
of  the  lever  to  the  fulcrum  FED.     But  if  an  elastic  fulcrum  be 


STEPS  OF  DISLOCATIONS. 


83 


substituted,  the  instant  the  string  breaks  the  weight-end  of  the  lever 
will  be  thrown  into  the  air  as  FE. 

Rotation  inward  is  an  almost  invariable  accessory  agent  in  pro- 
ducing dislocations,  and  the  query  arises  :  Is  there  a  special  agency 
in  dislodging  the  head  so  constantly  outward  ?  At  first  glance  one 
can  see  nothing  in  rotation  to  disturb  the  position  of  the  head ;  for 
were  the  femur  a  straight  bone  and  the  capsule  of  equal  strength  and 
length,  the  whole  might  be  twisted  off,  leaving  the  head  still  in  the 
socket.  Indeed,  it  seems  a  little  strange,  at  the  first  glance,  that  the 
head  should  not  be  as  frequently  displaced  inward  as  outward  by  the 

Fig.  69. 


act  of  inward  rotation.  The  solution,  however,  lies  in  the  fact  that 
in  rotation  inward  the  ilio-femoral  ligament,  which  is  by  far  the 
strongest  part  of  the  capsule,  lies  upon  the  inner  aspect  of  the  joint. 
(Fig.  69.)  As  rotation  increases  the  tension  of  the  capsule  increases, 
until  finally  the  lower  outer  portion,  pressed  upon  by  the  head,  gives 
way,  and  the  prevalent  portion,  feeling  no  longer  any  resistance, 
throws  the  head  outward. 

There  is  another  factor  concerned  in  the  leaping  of  the  head  from 
beyond  the  boundaries  of  the  socket,  and  that  is  found  in  its  globular 
shape.  As  the  head  is  spherical,  the  pressure  from  the  borders  of 
the  rent  increases  until  the  maximum  circumference  is  reached.  The 
instant  that  is  passed,  the  tissues  contracting,  often  very  powerfully, 


84  INTR OD  UCTOB  Y  STUD  Y. 

around  the  diminishing  globe  shoot  it  forward  with  a  sudden  spring. 
Simple  adduction  and  simple  rotation  may  be  quite  enough  to  rup- 
ture the  capsule,  but  when  the  head  is  shot  inward  into  the  thyroid 
depression  or  outward  upon  the  dorsum  (and  that  in  the  cadaver)  an 
agency  independent  of  leverage  or  live  muscle  must  be  invoked  to 
explain  it. 

3.  Shifting  of  the  head  to  a  point  more  or  less  remote  from  the 
position  it  reached  at  the  completion  of  the  second  stage.  Few, 
except  in  experimental  work,  see  the  head  in  the  position  to  which 
it  originally  escaped  in  the  second  stage.  The  unexpended  force, 
the  weight  of  the  limb,  transportation,  or  prior  unsuccessful  attempts 
at  reduction,  tend  to  shift  the  head  to  a  secondary  position.  In 
experimental  work  the  hardest  part  is  accomplished  when  the  capsule 
is  ruptured ;  after  this  any  variety  of  dislocation  may  be  easily  and 
perfectly  reproduced. 

An  Examination  into  the  Theory  that  Traumatic  Disloca- 
tions take  Place  through  Thrust. 

What  I  have  said  in  the  preceding  pages  about  the  steps  of  dislo- 
cations in  experimental  work  is  not  theory ;  I  have  repeatedly  wit- 
nessed it.  In  traumatic,  i.  e.,  clinical,  cases  we  are  obliged  to  theorize. 
Formerly  all  surgeons  believed,  and  many  still  believe,  that  in  trau- 
matic dislocations  the  head  passes  directly  to  its  point  of  destination  ; 
that  a  dislocation  upon  the  dorsum  ilii  is  produced  by  a  thrust  when 
the  thigh  is  extended  and  adducted,  and  that  a  thrust  directly  upward 
with  the  limb  extended  will  accomplish  an  infra-spinous  luxation, 
while  a  thrust  inward  as  the  thigh  is  abducted  will  produce  a  thyroid, 
perineal,  or  pubic  luxation. 

I  am  free  to  acknowledge  that  it  is  not  a  sufficient  argument  in 
refutation  of  such  a  theory  to  say  that  experimenters  have  never 
been  able  to  accomplish  a  dislocation  bi/  tlirust^  or  to  say  that 
Nature  need  not  adopt  a  difficult  mode  when  there  is  an  easier  one. 
I  shall,  however,  ask  the  reader  to  examine  with  me  the  steps  of 
a  few  accidental  dislocations  which  present  fairly  definite  data,  and 
if  he  will  do  so  without  prejudice,  I  hope  to  convince  him  that  dislo- 
cations usually  believed  to  be  due  to  thrust  are  no  exception  to  the 
mechanism  which  I  have  just  pointed  out. 

Problem  1.  A  man  walking,  steps  into  a  long,  narrow  hole,  falls 
forward,  and  dislocates  his  right  femur  upon  the  dorsum. 


STEPS  OF  DISLOCATIONS. 


85 


What  is  the  mechanism  of  dislocation  ?     Approximate  data  : 

1.  A  long  lever  immovably  fixed — i.  e.,  the  extended  limb  in  a  hole. 

2.  Weight,  the  body  of  the  man. 

3.  Direction  of  the  force  forward — /.  e.,  flexion  of  the  body  on 
the  thiorh. 

4.  Lever  attached  at  the  lower  right-hand  corner  of  the  trunk. 

5.  Resistance  to  dislocation,  the  capsule. 

The  reader  will  please  note  that  the  body  cannot  fall  forward 
indefinitely  upon  the  fixed  and  extended  limb.  It  will  be  checked 
by  the  hamstring  muscles  (Fig.  70,  dotted  line)  before  it  reaches  a 


Fig.  70. 


Fig.  71. 


Fig.  72. 


Flexion 


Flexion,  adduction,  and 
rotation  inward. 


right  angle.  Note  also  that  the  head  of  the  femur  is  attached  at  one 
corner  of  the  body ;  hence  the  instant  the  falling  trunk  is  checked 
at  one  point  (i.  e.,  in  flexion)  the  unsupported  part  of  the  body  (i.  e., 
the  opposite  corner)  drops  until  checked ;  and  now,  still  under  the 
force  gravity,  it  has  yet  only  one  direction  open  to  it,  viz.,  rotation 
inward — three  motions,  all  possible  to  a  ball-and-socket  joint.  All 
these  are  the  direct  result  of  falling  forward  upon  one  fixed  and  im- 
movable thigh.  The  three  motions  that  produced  the  luxation  are 
identical  with  forces  that  will  accomplish  the  same  end  upon  a  cadaver 
in  the  dissecting-room.^ 


1  The  order  in  which  I  have  stated  these  steps  is  purely  arbitrary.  It  would  be  equally 
true  if  I  had  stated  them  in  the  order  of  adduction,  rotation,  and  flexion.  It  is  not  the  order, 
hut  the  blending  of  these  forces  that  acts  so  eflfectively  in  dislodging  the  head  of  the  femur. 


86 


ISTRODUCTORY  STUDY. 


Answer  to  Problem  1.  The  head  was  dislocated  under  three  forces 
acting  together,  viz.,  flexion,  adduction,  and  rotation  inward. 

Problem  2.  A  tramp,  sitting  on  the  narrow  foot-wide  platform  at 
the  rear  of  a  freight  car,  with  his  left  leg  extended  and  resting  upon 


Fig. 


a  similar  platform  of  the  following  car,  has  his  left  femur  dislocated 
upon  the  dorsum  ilii  by  a  sudden  slowing  up  of  the  train  and  coming 
together  of  the  cars. 


Fig 


Query  :  What  was  the  mechanism  of  dislocation  ?  Approximate 
data : 

1.  The  left  limb  was  fully  extended.  (Fig.  73.)  Had  it  been 
flexed,  or  could  it  have  been  flexed  by  the  impact,  the  knee  would 
have  sprung  forward  and  no  injury  would  have  been  sustained.  The 
force  was  therefore  transmitted  directly  from  the  foot  to  the  pelvis. 


STEPS  OF  DISLOCATIONS.  87 

2.  The  force  does  not  strike  the  pelvis  squarely,  but  explodes 
upon  one  corner  of  it.    (Fig.  74.) 

3.  The  resistance  comes  from  the  perpendicular  back  of  the  car 
against  which  the  man  Avas  leaning.  The  man  was  not  sitting  erect. 
Had  he  been  he  could  not  have  fully  extended  his  limb.  The  resist- 
ance therefore  comes  from  the  dorso-lumbar  vertebra.  The  dislo- 
catino;  force  is  directed  from  below  and  to  the  left ;  the  resistance  is 
above  and  to  the  right.     (Figs.  74  and  75.)     The  resultant  of  these 

Fig.  75. 


three  co-operating  forces  must  be  the  answer  to  the  problem,  viz., 
flexion,  adduction,  and  rotation  inward. 

Problem  3.  J.  P.,  laborer,  was  engaged  in  shovelling  out  ballast 
from  the  hold  of  a  ship,  standing  on  the  bottom  with  his  feet  between 
the  ribs.  While  in  the  act  of  stooping  a  cave-in  from  above  struck 
him  upon  the  back  and  pelvis.  Result :  Dislocation  of  both  femurs : 
one,  dorsal  {i.  g.,  outward),  the  other,  thyroid  (inward). 

Query  :   What  Avas  the  mechanism  of  this  double  dislocation  ? 

Probable  data.  As  the  man  was  standing  in  a  semi-stooping  pos- 
ture, with  his  feet  between  the  parallel  ribs  in  the  bottom  of  the 
hold,  one  effect  of  the  cave-in  was  to  drive  him  upon  his  knees.  He 
would  thus  have  feet  and  legs  fixed  in  a  parallel  position.  A  second 
effect  would  be  to  flex  still  further  the  body  on  the  thighs.  If  the 
body  had  bent  squarely  upon  the  thighs,  simple  flexion  would  not 
have  dislocated  either.  As  both  legs  were  now  fastened  parallel, 
whatever  motion  the  thighs  took,  they  also  must  move  parallel.  If 
the  body  swayed,  one  thigh  would  be  adducted,  the  other  abducted. 
If  the  body  rotated,  the  rotation  in  one  hip  would  be  internal,  and 
that  in  the  other  of  necessity  external.  If  the  legs  were  fastened 
and  the  femurs  compelled  to  move  parallel,  then  flexion,  adduction, 
and  rotation  inward  in  one  limb  would   require  flexion,  abduction, 


88  INTBOD  UCl  OR  Y  STUD  Y. 

and  rotation  outward  in  the  other.  Thus  is  brought  about  a  double 
dislocation,  the  one  dorsal  and  the  other  thyroid,  and  by  the  appli- 
cation of  force  in  a  way  directly  opposed  to  the  theory  of  thrust. 

There  is  a  further  argument  in  support  of  the  theory  that  rotation 
inward  is  a  very  constant,  if  not  absolutely  essential,  element  in  the 
mechanism  of  dorsal  dislocations,  viz.,  that  rotation  inward  is  an 
almost  invariable  sign  and  accompaniment  of  dorsal  dislocations.  If 
rotation  inward  is  a  factor  in  producing  dislocations  outward,  the 
instant  the  head  bursts  through  the  capsule  a  still  greater  degree  of 
rotation  will  take  place,  while  the  head  falling  outside  the  socket 
falls  in  a  state  of  inward  rotation.  It  falls  until  arrested  by 
the  iliofemoral  ligament,  and  must  remain  in  a  state  of  inward 
rotation  until  the  neck  is  broken  or  the  outer  branch  of  the  ilio- 
femoral ligament  gives  way.  Rotation  outward  is  impossible,  be- 
cause any  attempt  to  accomplish  it  is  resisted  by  the  remnant  of 
untorn  capsule,  which  brings  the  head  against  some  part  of  the  outer 
surface  of  the  pelvis. 

Let  us,  however,  suppose  a  dislocation  to  be  possible  by  thrust 
through  the  extended  femur.  Let  it  be  possible  for  the  smooth  head 
to  spring  from  the  smooth  socket,  through  the  capsule,  on  the  outside 
of  the  socket.  Why,  I  ask ,  if  the  thrust  occurs  during  normal  eversion 
of  the  foot  (Fig.  76),  does  not  the  foot  remain  everted  ?  and  why, 
if  the  usual  mode  of  dorsal  dislocations  be  through  thrust  with  the 
thiorh  adducted  and  everted,  is  not  the  form  of  dislocation  known  as 
dorsal  with  eversion  the  most  common  of  all,  instead  of  being  very 
rare  ?  How,  I  ask,  will  the  holders  of  this  opinion  explain  the 
inward  rotation  of  90°,  when  they  evoke  no  other  agency  to  pro- 
duce a  dislocation  than  a  thrust  in  the  long  axis  of  the  extended, 
adducted,  and  everted  limb  ? 

In  defence  of  the  theory  that  direct  thrust  in  the  long  axis  of  the 
femur  is  competent  to  dislocate  directly  upon  the  dorsum  ilii  it  has 
been  urged  that  velocity  can  perform  wonders  ;  that  while  no  one 
can  push  a  tallow-candle  through  a  pine  board  an  inch  thick,  the 
candle  can  readily  be  shot  through  tlie  board.  Granting  that  cir- 
cumstances alter  cases,  I  urge  against  the  theory  of  velocity  that  a 
candle  with  a  bend  in  it  of  130°  could  not  be  shot  through  a  pine 
board,  nor  could  a  man  projected  with  the  velocity  of  a  bullet  sur- 
vive the  sudden  arrest.  So  also,  I  would  add,  if  a  man  sitting  on 
the  end  of  a  car  were  to  receive  a  thrust  from  another  car  going  at 


STEPS  OF  DISLOCATIONS. 


89 


the  highest  rate  of  speed,  the  strongest  probabilities  lie  in  the  direc- 
tion of  fracture,  not  dislocation. 


Fig.  7G. 


Resume  of  Mechanism  and  Effect  of  Traumatic 
Dislocations  of  the  Femur. 

1.  All  traumatic  dislocations,  unaccompanied  with  fracture,  are 
the  result  of  leverage. 

2.  When  the  femur  is  the  lever,  the  outer  (or  the  lower)  part  of 
the  rim  of  the  socket  acts  as  a  fulcrum. 

3.  Dislocations  through  leverage  of  the  shaft  of  the  femur  occur 
only  in  hyper-abduction  and  hyper-extension. 

4.  In  dislocations    through  rotation   the  bent    leg  becomes    the 
long  arm  of  the  lever  and  the  ilio-femoral  ligament  the  fulcrum. 


90  lyTR OD  UCl  OR  Y  STUD  Y. 

5.  In  the  mechanism  of  dorsal  {i.e.,  outward)  dislocations  rota- 
tion inward  is  a  necessary  factor. 

6.  Dislocations  inward  may  result  from  simple  adduction.  Ad- 
duction, rotation  outward,  with  extension,  will  also  produce  it. 

7.  Dislocation  through  leverage  pure  and  simple  makes  the  small- 
est opening  in  the  capsule. 

8.  Dislocation  through  rotation  usually  tears  all  but  the  ilio-femoral 
ligament. 

9.  The  rent  in  the  capsule  may  be  extensive  and  the  peri-capsular 
muscles  may  escape  entirely.^ 

10.  Dislocations  through  thrust  exerted  in  the  long  axis  of  the 
shaft  are  exceedingly  improbable. 

11.  When  the  history  of  a  case  points  to  thrust  the  element  of 
fracture  is  highly  probable. 

12.  In  all  injuries  in  which  thrust  is  an  element  (as  in  earth  fall- 
ing on  the  bent  trunk,  or  a  blow  in  the  long  axis  of  the  shaft)  a 
liability  to  subsequent  inflammatory  mischief  must  be  borne  in  mind. 

PHEXOMEXA  OF  DISLOCATIOXS-SIGXS  AXD  THEIR 

CAUSES. 

If  we  exclude  pain  (a  symptom  common  to  all  aggravated  trau- 
matisms), there  remains  not  a  single  symptom  of  dislocation.  The 
distinctive  and  peculiar  deformities  significant  of  dislocations  can  all 
be  accurately  reproduced  upon  the  cadaver.  They  should,  therefore, 
be  called  signs — certainly  not  symptoms. 

In  the  following  study  I  shall  take  up  the  simplest  and  most  fre- 
quent dislocations ;  explain  the  rationale  of  signs  peculiar  to  them  ; 
shoAV  how  by  slight  modifications  other  varieties  may  be  made,  and 
how  great  a  change  at  the  periphery  can  be  made  by  a  slight  central 
change.  I  wish  to  repeat  what  I  have  already  frequently  brought 
forward,  viz.,  that,  as  we  deal  with  lever  and  fulcrum  in  the  produc- 
tion of  dislocations,  so,  by  the  changed  positions  in  these  levers  and 
fulcrums,  we  may  interpret  the  positions  of  the  two  arms  of  the  lever 
as  well  as  the  nature  of  the  fulcrum.  I  shall  arrange  the  signs  of  all 
dislocations  under  two  general  heads,  viz.,  those  that  occur  upon  the 
inner  plane  and  those  that  take  place  upon  the  outer  plane  of  the 
pelvis. 

1  See  case  of  Kobert  S— ,  p.  69. 


PHENOMENA  OF  DISLOCATIONS. 


91 


Signs  Attending-  Dislocations  Inward. 

In  dislocations  inward  no  part  of  the  upper  end  of  the  femur  can 
lie  upon  as  low  a  plane  as  is  possible  in  dislocations  outward.  This  is 
best  illustrated  when  the  femurs  are  compared  in  the  flexed  position.^ 


Fig.  77. 


cV 


XF indicates  the  level  of  the  sockets  (the  limbs  are  placed  vertical ;  A,  normal ;  B,  thjToid ; 
C,  dorsal).    No  dislocation  inward  can  be  below  it ;  no  dislocation  outward  above  it. 

The  student  while  investigating  the  persistency  and  cause  of  signs 
must  bear  in  mind  the  agencies  under  which  dislocations  take  place; 
and  in  dislocations  inward  he  must  remember  the  following  facts : 

1.  All  dislocations  inward  occur  during  abduction.  Hence  it  is 
not  strange  that,  in  the  great  majority  of  cases,  abduction  is  a  promi- 
nent feature. 

2.  The  shortest,  closest,  and  by  far  the  most  controlling  attach- 
ment of  the  upper  end  of  the  shaft  of  the  femur  is  the  remnant  of 
untorn  capsule,  which  binds  the  oblique  line  of  the  femur  to  the  lower 
spine  of  the  ilium.  This  sole  remnant  of  capsule  has  a  one-sided 
action.  It  is  made  tense  by  rotation  inward,  and  resists  it.  It  holds 
the  limb  in  a  state  of  persistent  outward  rotation.     This  causes  the 

1  The  author  first  called  the  attention  of  the  profession  to  this  mode  of  measurement  in 
establishing  a  diagnosis  in  an  article  published  in  the  Medical  Times,  March  28, 1874.  Dislo- 
cation of  the  Hip — Sciatic  Variety. 


92 


INTRODUCTORY  STUDY. 


tendency  of  the  capsule  to  hold  the  femur  in  a  perpetual  state  of 
abduction  and  rotation  outward.  These  signs  will  not  be  invariably 
present.  They  may  be  greatly  modified,  but  in  most  cases  they  will 
be  typical  of  the  injury. 


Fig.  78. 


/UOr£M.LIG 


Dislocation  is  inward  into  the  thyroid  depression,  below  and  internal  to  the  bloodvessels. 
The  vessels  in  this  position  would  cross  the  neck.  The  constraint  is  due  to  the  trochanter 
resting  on  the  lower  rim  of  the  acetabulum,  held  in  position  by  the  remnant  of  untom 
capsule.    (See  Kg.  15.) 

In  dislocations  inward  the  trochanter,  the  head  of  the  femur,  and 
the  remnant  of  capsule  enter  largely  into  the  characteristic  deformity. 
In  a  typical  thyroid  luxation  (well  represented  in  Fig.  78)  the 
marked  constraint  under  the  twofold  heads  of  flexion  and  abduction 


PHENOMENA  OF  DISLOCATIONS. 


93 


are  due,  not  to  the  head  pressing  into  the  thyroid  depression,  but  to 
the  great  trochanter  resting  (^'.  e.,  impinging)  upon  the  lower  rim  of 
the  socket.  With  the  trochanter  caught  upon  the  lower  rim  of  the 
socket,  the  remaining  part  of  the  capsule  is  not  long  enough  to  per- 
mit of  full  extension  ;  hence  the  weight  of  the  thigh  and  leg  is  sus- 
pended upon  the  remnant  of  capsule.  (Fig.  78.)  It  must  be  observed 
that  the  fulcrum,  i.  e.,  the  ilio-femoral  ligament,  lies  between  the  head 
and  the  knee,  i.  e.,  that  the  femur  lies  obliquely  beneath  it.  Under 
these  circumstances,  the  weight  of  the  knee  would  naturally  swing 
it  inward  ;  but  to  do  so  the  head  must  swing  outward.  The  latter  is 
impossible.  Hence,  in  dislocations  into  the  thyroid  depression  there 
is  a  resistance  to  adduction  of  the  knee.  It  is  to  be  noted  further, 
that  the  position  of  the  foot  is  midway  between  rotation  outward  and 
inward,  i.  e.,  the  outer  and  inner  condyles  are  on  the  same  level.  In 
such  a  case  the  great  trochanter  will  be  found  on  a  level  with  the 
head. 

Fig.  79. 
A.  B. 


Dislocation  into  thyroid  depression.    Fascia  lata 
relaxed.    Great  trochanter  concealed. 


Normal  conditions.    Trochanter 
major  prominent. 


We  may  note  again  the  concealment  of  the  great  trochanter, 
and  contrast  it  with  the  bold  prominence  in  a  normal  condition. 
(Figs.  78  and  79.)  We  may  note  also  the  angle  of  depression  between 
the  crest  of  the  ilium  and  the  femur,  due  to  displacement  inward  of 
the  upper  end  of  the  femur,  and  to  the  relaxation  of  the  fascia  and 
muscles  on  the  outer  aspect  of  the  hip. 


94 


INTRODUCTORY  STUDY. 


Let  us  now  attempt  to  flex  the  femur  to  a  vertical  position.  The 
head  lies  on  the  thyroid  depression.  There  will  be  no  obstacle  to 
flexion.  But  when  the  attempt  is  made  to  place  the  femur  in  a 
vertical  position  the  pelvis  will  be  found  to  move  with  it.  (Fig.  81.) 
If  vfe  contrast  Fis;.  80  with  Fig.  81,  we  shall  see  that  the  abduction 
has  not  been  relieved ;  that  it  is  the  same  in  each  position ;  that  the 
pelvis  has  been  canted,  and  nothing  more.  Note  in  Fig.  80,  in 
which  the  abduction  is  apparent,  that  the  sockets  are  on  the  same 
level.  Note  in  Fig.  81,  in  which  the  abduction  is  apparently  over- 
come, that  the  sockets  are  not  on  the  same  level.  Two  things  should 
be  borne  in  mind:  First,  adduction  in  dislocations  inward  is  resisted. 
Second,  if  the  two  femurs  are  to  be  compared,  see  that  the  sockets 
are  on  the  same  level,  otherwise  the  dislocated  limb  will  appear  much 
longer  than  its  fellow. 


Fig. 


Fig.  81. 


Should  the  troshanter  slip  ofi"  the  lower  rim  and  into  the  socket  (Fig. 
82)  there  will  be  quite  a  marked  change  in  the  position  of  thigh  and 
leg.  First,  as  to  constraint.  This  will  be  decidedly  less.  The  trochan- 
ter lies  nearer  the  socket,  and  the  remnant  of  capsule  Avhich  supports 
the  weight  of  the  thigh  and  leg  is  not  put  upon  the  stretch  until  the 
thigh  is  more  extended.  The  trochanter  may  lie  well  in  the  socket, 
or  but  partially,  according  as  it  is  empty  or  occupied  by  capsule  or 
muscle.     The  neck  crosses,  and  may  rest  upon  the  inner  rim  of  the 


PHENOMENA  OF  DISLOCATIONS. 


95 


socket.  The  head  may  rise  and  be  a  little  more  prominent ;  or,  if 
the  abduction  is  considerable,  it  may  still  remain  in  the  thyroid 
depression.     In  both  of  the  conditions  described  the  trochanter  and 


Fjg.  82. 


Contrast  this  with  Fig.  78.  The  head  by  rotation  outward  has  been  shifted  upward  ;  it  has 
escaped  from  beneath  the  femoral  vessels  which  now  lie  inward  or  they  still  cross  the  head. 
{Cf.  Fig.  15.)  The  trochanter  now  lies  in  the  socket,  and  very  much  of  the  constraint  has 
disappeared. 


the  capsule  give  character  to  the  deformity.  In  this,  as  in  the  former 
case,  the  ilio-femoral  ligament  (fulcrum)  lies  across  the  two  arms  of 
the  lever.  If  the  long  arm  (knee)  is  carried  inward,  it  will  be  resisted, 
because  the  short  arm  cannot  move  outward.     With  the  exception  of 


96 


INTB  OD  UCTOB  Y  SI  UD  Y. 


restraint,  most  that  has  been  said  of  i\iQ  first  condition  is  present  in 
the  second.  The  trochanter  major  is  lost  in  both.  Rotation  may 
make  the  head  prominent,  but  not  the  trochanter.  If  the  limbs  are 
compared  vertically,  all  that  has  been  said  about  adduction  and  the 


Fig.  83. 


The  head  is  now  entirely  outside  of  the  femoral  vessels  ;  it  has  been  rotated  further  upward 
and  outward.  Trochanter  is  now  in  the  thyroid  space  and  caught  beneath  the  overhanging 
ledge  of  the  ramus. 

tilting  of  the  pelvis  must  be  borne  in  mind.  In  neither  case  is 
rotation  exajiserated.  In  both  rotation  inward  will  be  resisted,  but 
rotation  outward  will  be  possible ;  and  in  this  way  only  can  the  head 
be  forced  into  prominence. 

If,  under  the  conditions  just  described,  the  ankle  of  the  bent  leg  be 


PHENOMENA  OF  DISLOCATIONS. 


97 


raised  and  the  femur  be  rotated  upon  its  axis  outward,  the  effect  will 
be  to  lift  the  trochanter  out  of  the  socket  and  to  plant  it  in  the  thyroid 
depression.  (Fig.  83.)  Once  in  the  thyroid  depression,  it  may  abut 
against  the  under  surface  of  the  horizontal  ramus  that  forms  the  upper 
boundary  of  the  depression.  Under  these  circumstances  there  is  a  little 


Fig. 


Originally  a  thyroid— now  may  be  appropriately  styled  a  reversed  thyroid.    All  restraint 
has  now  disappeared.    Note  the  extreme  pointing  backward  of  the  foot. 

fixation.  The  weight  of  the  limb  is  supported  by  the  remnant  of  cap- 
sule, but  the  fixed  position  in  abduction  and  semiflexion  is  due  to  the 
trochanter  being  caught  beneath  the  pubic  ramus.  Note  that  the 
inner  malleolus  and  the  inner  condyle  are  looking  upward.  The  head 
must  therefore  look  upward.     Note  that  the  foot  looks  outward  and 

7 


98 


IN  TROD  UCTOR  Y  SI  UD  Y. 


the  heel  inward.  Look  inward,  then,  for  the  great  trochanter.  The 
ilio-femoral  ligament  crossed  the  lever  in  front  in  Figs.  78  and  82; 
in  Fiof.  83  it  lies  to  the  outside.  Let  the  reader  bear  in  mind  that 
the  remnant  of  untorn  capsule  (the  ilio-femoral  ligament)  is  holding 
the  base  of  the  neck  of  the  femur  to  the  lower  spine  of  the  ilium  ; 
that  it  may  rotate  about  it,  but  cannot  get  away  from  it.  Note  that 
the  head  is  getting  into  greater  prominence  through  rotation  outward, 
but  that  the  trochanter  major  is  still  obscured. 

The  position  of  the  trochanter  beneath  the  ledge  of  the  horizontal 
ramus  is  precarious.  The  slightest  rotation  outward  will  lift  the  tro- 
chanter out  of  the  hollow,  Avhen  it  will  rise  and  rest  upon  the  promi- 
nence on  the  inner  side  of  the  socket.  (Fig.  84.)  Now  all  constraint  is 
at  an  end ;  the  femur  hangs  from  the  lower  spine  ;  there  is  no  flexion 
or  abduction.  The  most  important  clue  to  the  position  of  the  head 
is  rotation  outward.  Query.  Where  is  the  head  ?  the  trochanter  ? 
the  Y-ligament  ?  Answer.  Look  at  the  foot :  the  toes  are  looking 
backward,  the  internal  malleolus  is  looking  outward ;  then  the  head 
must  be  looking  outward,  and  the  trochanter  must  lie  inward  and 


rest  upon  the  inner  plane.  It  would  not  rest  upon  the  inner  plane 
if  it  had  been  primarily  a  dorsal  dislocation.  It  is  therefore  a  dis- 
location Avith  extreme  rotation  outward,  from  an  original  thyroid,  as 
can  be  seen  by  a  glance  at  the  reduced  figures  of  82,  83,  84. 

Study  of  the   Signs  Attending  Dislocations  Outward. 

I  began  the  explanation  of  the  phenomena  of  dislocations  inward 
by  stating  that  in  this  variety  of  displacement  the  trochanter  major 


PHENOMENA  OF  DISLOCATIONS. 


99 


is  brought  into  close  contact  with  the  pelvis ;  that  it,  and  not  the 
head,  rests  upon  the  bony  platform  ;  and  that  the  peculiar  deformity 
is  mainly  due  to  the  trochanteric  end  of  the  shaft  and  the  untorn 
part  of  the  capsule. 

Not  so  in  dislocations  outward.  In  scarcely  any  position  can  the 
trochanter  be  made  to  touch  or  rest  upon  the  pelvis.  In  this  variety 
the  head  and  neck  abut  against  the  outer  side  of  the  pelvis,  and  the 
constraint  brought  about  by  the  tense  remnant  of  the  capsule  (ful- 
crum) and  the  short  end  of  the  lever  (head  and  neck)  is  of  a  very 
different  character  from  that  which  takes  place  in  dislocations  inward. 

Two  facts  should  be  recalled  at  the  outset : 

1.  That  rotation  inward  is  a  prime  factor  in  producing  all  dislo- 
cations outward. 

2.  That  the  shortest,  closest  bond  between  the  socket  and  the 
femur  is  the  remnant  of  untorn  capsule — the  ilio-femoral  ligament. 


Fig.  85. 


If  a  dislocation  outward  and  downward  between  the  obturator 
tendons  could  be  arrested  at  the  instant  the  head  drops  and  the 
whole  weight  of  the  limb  is  arrested  by  the  ilio-femoral  ligament, 
the  appearance  would  not  be  unlike  that  shown  in  Fig.  85.  But  the 
limb  cannot  remain  in  this  position  ;  it  is  not  balanced  ;  the  weight 
of  the  leg  drags  the  thigh  downward. 

As  the  knee  descends  it  inclines  inward  toward  the  sound  limb, 
because  the  head  and  neck,  which  constitute  the  short  arm  of  the 


100 


INTRODUCTORY  STUDY. 


lever,  lie  outward,  and  the  short  fulcrum  (the  tense  and  strong  ilio- 
femoral ligament)  compels  the  long  arm  of  the  lever  to  move  inward 
as  it  descends. 

The  full  understanding  of  this  inward  tendency  of  the  long 
arm  of  the  lever  is  of  the  utmost  importance,  and  it  is  very  easy 
of  comprehension.  All  depends  on  the  situation  of  the  fulcrum. 
This  lies  between  the  two  arms  of  the  lever.  If  the  long  arm 
(knee)  would  move  outward,  the  short  arm  (neck  and  head)  must 
move  inward.     This  is  impossible.    Under  no  circumstances  can  the 


Fig.  86. 


short  arm  move  inward ;  the  outer  wall  of  the  pelvis  prevents  this. 
So  long  as  the  fulcrum  (the  halter — the  remnant  of  untorn  capsule) 
is  short  the  knee  cannot  be  moved  out.  If  the  neck  of  the  femur 
{i.  e.,  the  short  arm  of  the  lever)  be  broken  or  the  fulcrum  (halter) 
be  lengthened  (<".  e.,  if  the  ilio-femoral  ligament  be  torn),  then  the 
knee  may  be  moved  outward  ;  but  under  no  circumstances  can  the 
short  arm  of  the  lever  move  inward. 

This  accounts  for  the  turning  in  of  the  knee.     But  how  shall  we 
account  for  the  rotation  inward  of  the  axis  of  the  femur  ? 


PHENOMENA  OF  DISLOCATIONS. 


101 


The  immediate  or  temporary  rotation  may  be  explained  from  the 
circumstance  that,  in  all  outward  dislocations,  rotation  inward  is  an 
efficient  factor  at  the  instant  the  capsule  ruptures,  and  that  a  sudden 
increase  of  rotation  inward  takes  place,  when  the  resistance  from  the 
capsule  ceases  and  the  head  drops  outward. 

The  persistent  inward  rotation,  however,  rests  on  a  very  different 
basis.  This  is  not  due  to  any  original  force  in  dislocation,  or  to  any 
muscular  action  after  it.  It  can  be  readily  demonstrated  upon  the 
cadaver,  and  it  persists  during  anaesthesia.  The  mechanism  of  this 
is  simple.     In  the  accompanying  diagrams  I  represent  (Fig.  87)  the 


Fig.  87. 


Fig.  88. 


head  in  its  socket  and  the  ilio-femoral  lio-ament  extending  from  the 
lower  spine  to  the  base  of  the  neck  of  the  femur.  In  Fig.  88  the 
head  is  dislocated  downward  and  the  trochanteric  end  of  the  shaft  is 
now  suspended  upon  the  ilio-femoral  ligament.  If  the  head  is  to  be 
rotated,  it  must  rotate  upon  the  shaft  as  a  centre,  and  the  shaft  must 
rotate  upon  the  attached  capsule.  Any  such  rotation  brings  the 
head  (see  arrow)  against  the  side  of  the  outer  wall  of  the  pelvis, 
which  arrests  it.  The  persistency  of  this  sign,  viz.,  rotation  inward, 
for  years,  or  possibly  for  life,  depends  upon  the  persistency  of  the 
elements  that  originally  produced  it.  Time  may  modify  it.  Thus 
the  dislocated  head  may  be  flattened  or  the  halter  (untorn  remnant 
of  capsule)  lengthened  by  long-continued  use. 

A  lad  dislocated  his  hip  with  all  the  signs  of  dislocation  outward. 


102 


IXTE OD  UCTOR  Y  STUD  Y. 


He  grew  up  to  be  a  man,  and  led  an  active  life.  The  inversion 
gradually  changed,  until  late  in  life  he  had  eversion  instead  of 
inversion. 

In  Fig.  89  the  upward  progress  of  the  hip  is  seen  to  be  arrested 
by  the  obturator  internus.  This  is  what  Bigelow  terms  "  dorsal 
below  the  tendon."  He  lays  great  stress  upon  it,  and  makes  a 
distinct  variety  of  it.  "With  Morris,  I  am  of  the  opinion  that  the 
eminent  author  laid  too  much  stress  upon  this  point. 


'BJURHTOR 
eXTERNUS 
OBTUff^rO/l 


Right  hip  dislocated  outward.  Xeck  embraced  between  the  two  obturators.  Compare  Fig. 
89  with  Fig.  14-i.  In  the  left  hip,  which  is  in  place,  the  arrow  indicates  the  path  of  the  head 
taken  by  the  dislocated  right  hip. 


If  the  head  be  arrested  by  the  tendon  of  this  muscle,  it  will  lie 
nearly  opposite  the  lower  half  of  the  great  sciatic  foramen,  and  will 
manifest  considerable  constraint.  In  the  majority  of  cases  this  muscle 
is  torn  in  the  act  of  dislocation,  and  yet  the  signs  persist  as  if  the 
tendon  enjoyed  its  fullest  integrity.     By  a  return  to  Case  X.  (p.  ^^^ 


PHENOMENA  OF  DISL  0  CA  TIONS.  103 

it  will  be  seen  that  the  limb  was  inverted  and  adducted,  that  it  crossed 
the  symphysis  pubis,  and  was  immovably  fixed  in  this  position  ;  and 
yet,  on  dissection,  the  tendon  of  the  obturator  internus  lay  across 
the  head,  torn  from  the  muscle  of  which  it  is  a  part. 

I  have  described  the  two  characteristic  signs  of  outward  disloca- 
tion, viz.,  rotation  inioard  and  adduction,  and  have  shown  that  they 
are  both  dependent  upon  the  length  and  position  of  the  fulcrum  {i.  e., 
the  remnant  of  untorn  capsule).  It  will  not,  therefore,  surprise  the 
student  to  learn  that  with  a  greater  degree  or  total  laceration  of 
this  bond  of  union  (in  other  words,  with  the  removal  of  the  fulcrum) 
both  these  signs  of  dorsal  dislocation  vrould  disappear. 

We  may  thus  have  dorsal  dislocation  ivithout  adduction,  and  dorsal 
dislocation  with  e version. 

("Everted  dorsal"  will  be  discussed  under  Dislocations  Practi- 
cally Considered.) 

Aids  to  Diagnosis — General  Consideration. 

It  is  obviously  impossible  for  any  one  to  diagnosticate  a  dislocation 
of  the  femur  who  is  not  an  expert  in  hip-joint  disease  and  in  fracture 
of  the  neck. 

I  have  little  to  say  further  than  to  put  the  inexperienced  upon 
their  guard,  lest  they  be  too  easily  satisfied  with  first  impressions. 

If  an  experienced  surgeon  pronounces  a  fracture  of  the  neck  a 
sprain,  fails  to  recognize  a  dislocation,  or  gives  an  anaesthetic  "  to 
set"  a  case  of  hip-joint  disease,  a  young  and  inexperienced  one  has 
reason  to  fear  that  he  may  fall  into  like  errors. 

I  would  guard  the  reader  against  some  too-prevalent  errors : 

First.  A  snap  diagnosis.  This  the  most  experienced  have  too 
often  occasion  to  regret.  Give  patient  scrutiny  to  every  detail  of  the 
history  of  the  accident.  Remember  that  occasionally  persons  rise 
up  and  walk  after  a  dislocation,  or  after  a  fracture  of  the  neck  of 
the  femur.  Patients  sometimes  purposely  mislead  by  exaggerating 
former  injuries,  or  a  drunken  patient  may  not  be  believed,  and  an 
old  disorder  may  be  mistaken  for  a  recent  injury.  Such  a  mishap 
is  reported  and  had  a  fatal  issue. 

In  the  preliminary  examination  made  with  the  patient  conscious, 
it  would  be  a  wholesome  safeguard  against  error  to  have  him  out  of 
bed,  standing,  and  naked. 

Second.  The  use  of  an  anaesthetic  as  an  aid  in  diagnosis.   Valuable 


104 


INTRODUCTORY  STUDY. 


as  this  may  be,  do  not  resort  to  it  until  a  careful  study  of  the  case 
has  been  made;  and  during  the  examination  do  not  forget  that 
serious,  if  not  irremediable,  harm  may  be  done  to  a  coxalgic  joint  or 
to  an  impacted  fracture  of  the  neck. 

Third.  Do  not  place  too  high  a  value  upon  the  data  or  information 
that  may  be  obtained  from  measurements.  If  you  are  dealing  with 
a  thyroid  dislocation,  remember  that  in  one  instance  lengthening,  in 
a  second  shortening,  and  in  a  third  no  difference,  has  been  recorded. 
In  one  instance  of  dorsal  dislocation,  Avitli  apparently  great  dis- 
crepancy in  the  lengths  of  the  two  limbs,  the  apparently  shorter  and 
dislocated  limb  was,  on  measurement,  found  to  be  longer  than  its 
apparently  longer  fellow. 

Fig.  90. 


Measurements  may  be  deceptive  on  account  of  asymmetry  of  the 
pelvis.  If  the  head  of  the  femur  is  ankylosed  in  an  abducted  posi- 
tion, and  the  two  ankles  are  compared  in  the  horizontal  position, 
there  will  be  marked  shortening  of  the  sound  limb,  or,  what  amounts 
to  the  same  thing,  marked  lengthening  of  the  affected  one.     It  is 


-  PHENOMENA  OF  DISLOCATIONS. 


105 


therefore  of  vital  importance  that  the  pelvis  and  trunk  be  placed  in 
a  normal  position,  and  both  limbs  examined  in  corresponding  rela- 
tions to  it.  The  accompanying  outline-drawing  is  from  a  photograph 
of  a  young  man  supposed  to  have  dislocation  of  the  right  femur.  A 
consultation  was  called  to  reduce  it.  The  diagnosis  was  made  at  a 
renowned  medical  school,  at  which  the  patient  sought  relief.  For- 
tunately better  counsel  prevailed  before  an  anaesthetic  was  adminis- 
tered. In  the  figure  the  patient  is  standing  on  his  abducted  anky- 
losed  limb,  assisted  by  his  adducted  limb.  When  the  adducted  limb 
was  abducted  to  correspond  with  its  fellow  (i.  e.,  carried  out  to  Z) 
the  asymmetry  disappeared. 


Fig.  91. 


XY  indicates  the  level  of  the  sockets  when  the  limbs  are  placed  vertical, 
inward  can  be  below  it ;  no  dislocation  outward  above  it. 


No  dislocation 


I  have  already  stated  that  if  the  pelvis  is  placed  on  its  back 
the  sockets  are  midway  between  the  level  of  the  pubes  and  the 
sacrum.  I  have  also  stated  that  the  bony  pelvis  slopes  upward 
toward  the  pubes  and  downward  toward  the  sacrum.  This  condi- 
tion can  be  turned  to  a  valuable  diagnostic  service,  if  we  examine 
the  limbs  flexed  upon  the  pelvis  as  indicated  in  the  diagram  (Fig.  91). 
By  reference  to  this  it  will  be  seen  that  if  the  head  lies  in  the  socket 
(J-),  or  on  the  bony  platform  internal  to  it  (B),  that  it  (the  head)  will 


106 


INTR OD  UCTOB  Y  STUD  Y. 


have  a  support,  while  if  it  is  dislodged  outward  (C),  it  will  have  no 
bony  support,  and  will  hang  from  the  socket  by  a  remnant  of  capsule. 


Fig.  92. 


Another  valuable  point  to  bear  in  mind  is,  that  the  femur  (thigh) 
is   about   equal  in   length  to  the  tibia  and   tarsus  (leg  and  heel). 


Fig.  93. 

P(/B£S 


Hence  if  the  head  is  in  the  socket  and  the  knee  is  vertical,  the  sole 
of  the  foot  will  swing  clear  of  the  floor — i.  e.,  it  will  be  on  a  level 
with  the  socket.  The  same  will  also  be  true  if  the  head  be  dislo- 
cated inward  (Fig.  92);  not  so  if  the  head  is  dislocated  outward. 
Under  such  circumstances,  with  the  knee  vertical,  the  sole  of  the 


PHENOMENA  OF  DISLOCATIONS.  107 

foot  will  touch  upon  the  floor,  while  the  corresponding  shortness 
will  show  itself  hy  a  comparison  of  the  vertical  knees. 

A  point  which  writers  lay  stress  upon  is  that  the  great  trochanter 
is  much  depressed  in  dislocations  inward  (i.  e.,  lies  abnormally 
inward  toward  the  socket).  While  this  is  true,  it  is  also  true  that 
in  most  forms  of  dislocation  the  trochanter  lies  nearer  the  socket  than 
the  head  does.  It  should  be  constantly  borne  in  mind  that  the  head 
is  free  after  dislocation,  but  that  the  trochanter  is  bound  by  the 
remnant  of  untorn  capsule  to  the  anterior  inferior  spine  of  the 
ilium.  Hence  the  mere  fact  of  the  trochanter  lying  near  the  socket 
is  not  in  itself  diagnostic.  The  position  of  the  trochanter  should, 
however,  with  the  internal  condyle,  enable  the  examiner  to  locate 
the  head. 

Cleaning-  Out  the  Socket. 

In  experimental  work  muscular  fibre  becomes  pulpified  by  manipu- 
lation and  is  readily  pushed  before  the  head  into  the  socket.  Mus- 
cular debris  and  muscular  structure  may  be  conveyed  from  the 
pubo-ischiatic  plane,  and  parts  of  the  capsule  from  either  plane.  I 
have  not  infrequently  conveyed  so  much  detached  muscular  material 
into  the  socket  as  to  give  the  restored  limb  a  constrained  position, 
and,  were  it  not  that  I  could  see  and  fully  comprehend  the  difficulty,  I 
might  have  been  led  to  accept  the  theory  of  partial  reduction  due  to 
some  other  cause.  That  which  I  have  observed  in  my  work  has  been 
found  to  be  present  in  deaths  from  accidents,  in  which  the  dislocated 
head  had  been  reduced,  but  in  which  the  socket  was  found  to  be 
partly  filled  with  pulp  or  fragments  of  muscle.      (See  p.  67.) 

When  I  first  noticed  this  eff'ect  of  manipulation  I  was  inclined  to 
believe  there  was  no  remedy,  and  that,  though  the  head  was  nomi- 
nally restored,  dislocation  would  readily  recur  in  some  cases,  while  in 
all  the  amount  of  foreign  matter  might  ultimately  lead  to  mischief. 
Further  consideration  suggested  that  as  the  difficulty  was  one  of  my 
ow^n  creation  a  partial  or  complete  remedy  might  be  devised.  The 
reader  will  please  note  the  following  points  : 

First.   The  shape  of  the  head  and  neck. 

Second.  The  law  of  attachment  of  the  foreign  substance. 

Third.   The  door  of  entrance  of  the  foreign  substance. 

In  the  accompanying  diagrams  I  represent  the  head  joining  the 
neck  by  an  abrupt  offset  in  order  better  to  illustrate  my  meaning. 


108 


INTRODUCTORY  STUDY. 


By  such  a  shape  the  edge  or  corner  can  be  insinuated  behind  any- 
thing that  has  been  pushed  before  the  head  and  which  lies  within 
and  upon  the  floor  of  the  socket.  Now  anything  that  has  been 
pushed  before  the  head  (muscular  fibre,  parts  of  muscles,  or  capsule) 


Fig.  94. 


Fig.  95. 


Fig.  96. 


Capsule  everted. 

is  attached,  if  at  all,  to  the  pelvis.  Nothing  attached  to  the  femur 
is  likely  to  be  pushed  before  it ;  such  material  rather  follows,  or  is 
dragged  after  it,  in  the  efforts  of  manipulation.  Hence,  if  it  be  any 
portion  of  the  capsule  that  is  turned  in,  it  is  the  pelvic ;  it  cannot 
be  the  femoral  portion.  As  it  is  the  pelvic,  it  can  enter  only  a  given 
distance;  it  cannot  extend  indefinitely.  Finally,  all  the  foreign 
substance  that  enters  the  socket  must  enter  at  its  lowest  segment. 
At  this  part  the  head  escaped,  and  here  usually  free  access  to  the 
socket  was  established.  As  the  head  drove  the  foreign  substance 
into  the  socket  at  its  lower  section  during  manipulation,  so  during 
manipulation  the  foreign  substance  must  be  evicted  by  the  head 
and  expelled  at  the  door  of  entrance.  It  is  important  to  note  that 
the  side  of  the  head  that  drives  the  capsule  before  it  into  the  socket 
cannot  be  made  available  to  remove  it.  This  must  be  done  by  the 
opposite  side,  as  shown  in  the  diagram.     Hence,  if  the   capsule 


Fig.  97. 


Fig.  98. 


has  been  pushed  into  the  socket  from  the  dorsal  aspect,  the  first 
step  is  to  flex  and  abduct ;  while,  if  the  entrance  has  been  made 
from  the  thyroid  aspect,  the  femur  must  be  flexed  and  adducted  to 
accomplish  the  same  end.     After  engaging  the  inverted  capsule  the 


ROTATION  AND  CIRCUMDUCTION.  109 

femur  should  be  rotated  inward  to  tighten  the  Y-ligament  and  drive 
the  head  down  into  the  socket,  while  at  the  same  time  the  knee  is 
raised  and  the  foreign  matter  is  removed  from  the  socket. 

The  success  of  the  manoeuvre  Avill  be  apparent  by  the  free  and 
unembarrassed  motion  of  the  femur.  I  have  in  experimental  work 
repeatedly  pushed  so  much  muscular  fibre  or  capsule^  before  the  head 
as  to  prevent  extension  within  twenty-five  degrees  of  the  normal,  and 
to  check  adduction  and  extension.  In  some  cases  the  infrincrement 
was  less  marked,  but  in  every  case  the  socket  was  cleaned  out, 
and  the  full  extent  of  motion  was  re-established  by  the  method 
just  described.  From  an  experimental  standpoint  only  I  would 
urge  upon  every  one  the  importance  of  testing  the  degree  of  extension 
and  adduction  after  every  reduction, 

Bigelow,  after  a  reduction,  found  that  the  femur  did  not  resume 
normal  extension,  but  remained  semiflexed  and  abducted.  He  ac- 
cordingly cut  subcutaneously  some  tense  fibres  of  the  tensor  vaginae 
femoris,  which  only  partially  relieved  the  deformity.  The  subse- 
quent history  of  the  case  was  to  the  effect  that  the  patient  never 
recovered  the  use  of  the  joint.  In  this  case  the  symptoms  point  to 
a  foreign  substance  within  the  socket. 

ROTATION    AND    CIRCUMDUCTION:    THEIR    DEPORT- 
MENT BEFORE  AND  AFTER  DISLOCATION. 

In  rotation  the  entire  shaft  of  the  femur  turns  on  its  long  axis 
similarly  to  the  motion  of  a  gimlet. 

In  circumduction  the  knee  moves  in  a  circle,  of  which  the  head  of 
the  femur  is  the  centre. 

Observation.  It  is  possible  to  rotate  without  circumduction ;  to 
circumduct  without  rotation  ;  also  to  combine  both  movements  in  a 
single  manipulation. 

Rotation :  The  term  is  derived  from  rota,  a  wheel.  The  spokes 
of  a  wheel  rotate  about  the  axle,  which  is  at  rio-ht  ansjles  to  them. 
In  a  like  sense  Bigelow  speaks  of  the  bent  leg  as  the  spoke  of  a 
wheel  whose  axle  is  the  femur.     Strictly  speaking,  the  axis  of  motion 

1  When  I  have  reduced  the  head  into  a  hooded  socket  (Figs.  42  and  45,  Z)  I  have — during 
efforts  to  get  the  rim  of  the  head  beyond  the  borders  of  the  hood — experienced  a  sudden  re- 
lease which  told  me  that  the  head  was  now  at  the  bottom  of  the  socket  and  beyond  the 
hood.  I  could  then  turn  out  the  capsule  and  exult  in  an  empty  socket  and  freest  motion, 
and  this,  of  course,  entirely  through  manipulation. 


110  I^'TB  OD  UCTOR  Y  ST  UD  Y. 

does  not  lie  in  the  shaft,  because  the  femur  is  not  a  straight  bone. 
The  true  axis  of  motion  (Fig.  99,  A  B)  is  an  imaginary  line  passing 
through  the  knee  and  the  head  of  the  femur.  This  is  not  a  foolish 
refinement ;  it  is  a  fact  of  practical  value.  By  a  glance  at  the  figui'e 
it  will  be  seen  that  the  head  being  in  the  true  axis,  A  B,  does  not 
perceptibly  move,  but  that  the  great  trochanter,  lying  outside  the 
true  axis,  moves  upon  the  arc  of  a  circle  whose  radius  equals  in  length 
the  length  of  the  neck  of  the  femur.  This  suggests  a  useful  study. 
Every  student  should  familiarize  himself  Avith  the  amount  of  normal 
movement  of  the  trochanter  in  rotation,  so  that  he  may  be  able  to 
detect  any  defect  in  the  shortened  or  impacted  neck  of  the  broken 
femur  or  the  restricted  motion  of  an  inflamed  joint. 


Rotation  is  of  two  kinds  :  internal  and  external.  If  the  student 
stands  erect,  he  can  rotate  the  femur  inward  by  turning  the  toes 
inward,  and  rotate  outward  by  a  contrary  movement.  Keeping 
these  two  motions  distinctly  in  mind,  let  him  flex  the  leg  on  the 
thigh  to  a  right  angle,  and  now,  if  he  wishes  to  rotate  imvard,  he 
must  turn  the  foot  and  ankle  as  a  crank  outward ;  if  he  wishes  to 
rotate  outward  he  must  carry  the  foot  and  ankle  inward. 

In  the  reduction  of  dislocations  by  manipulation  the  patient  lies 
on  his  back,  the  thigh  is  placed  perpendicular,  and  the  leg  at  right 
angles  to  it.  Now,  remember  that  the  terms  "rotation  inward" 
and  "rotation  outward"  have  no  reference  to  the  position  of  the 
head,  but  simply  to  the  movement  just  described,  and  that,  no  matter 


ROTATION  AND  CIRCUMDUCTION. 


Ill 


where  the  head  is,  rotation  inward  requires  the  ankle  of  the  bent 
leg  as  a  crank  to  be  drawn  outward,  while  rotation  outward  requires 
the  ankle  of  the  bent  leg  to  be  carried  inward. 

After  dislocation  the  head  is  no  longer  the  pivotal  centre.  Now 
the  head,  freed  from  all  attachments,  moves  in  the  circumference  of 
a  circle,  of  which  the  neck  is  the  radius.  The  constraint  (or  ful- 
crum) on  which  rotation  depends  is  furnished  by  the  untorn  portion 
of  the  capsule.  The  trochanter,  bound  to  the  inferior  spine  over 
the  socket  by  the  ilio-femoral  ligament,  ceases  to  have  its  normal 
range  of  motion,  and  may,  without  much  inaccuracy,  be  regarded  as 
the  pivot  of  motion.  Now,  though  not  strictly  true,  it  may  be  said 
that  the  true  axis  of  motion  runs  through  the  shaft  of  the  femur. 


Fig.  100. 
A' 


Thus  things  are  reversed.  Before  dislocation  the  trochanter  rotated 
about  the  head ;  after  dislocation  the  head  rotates  around  the  tro- 
chanter. One  point,  which  will  bear  many  repetitions,  is  that,  if 
after  dislocation  the  head  revolves  about  the  trochanter,  the  very 
motion  of  rotation  will  bring  the  head  or  neck  against  any  obstacle 
that  is  close  to  the  socket. 

Circumduction  means  to  lead  around.  Circumduction  can  be  prac- 
tised on  the  flexed  or  extended  limb.  As  employed  in  attempts  at  re- 
duction, the  patient  lying  on  his  back,  the  thigh  is  flexed  to  a  perpen- 
dicular, while  the  leg  is  used  at  a  right  angle  to  it.  (Fig.  101.)  In  the 
normal  joint  only  the  head  lies  in  the  axis  of  motion,  while  the  knee  can 
be  made  to  sweep  around  in  circles  of  gradually  increasing  diameter. 


112 


INTRODUCTORY  STUDY. 


Circumduction  may  be  either  inward  or  outward,  and,  simple  as  it 
may  seem,  it  is  often  difficult  to  comprehend  what  an  author  means 
when  he  says  "  circumduct  inward  "  "or  circumduct  outward.''  If  the 
knee  is  abducted  at  right  angles  to  the  pelvis,  circumduction  inward 
may  mean  upward  and  inward  or  downward  and  inward.  If  the 
knee  lies  over  the  pubes,  circumduction  outward  may  be  upward  and 
outward  or  downward  and  outward.  As  it  is  impossible  to  give 
concise  directions  that  cannot  be  misunderstood,  surgeons  should 
always  describe  fully  the  manoeuvre,  preferring  the  charge  of  pro- 
lixity to  that  of  ambiguity. 


Fig.  101. 


After  dislocation  a  constraining  force  is  pre.sent  when  rotation 
and  circumduction  are  employed,  and  this  force  is  the  untorn  rem- 
nant of  capsule ;  but  the  effect  is  widely  diverse  in  the  one  from 
the  other.  In  rotation  the  ligament  is  wound  up,  and  necessarily 
draws  the  head  nearer  the  socket.  Very  unlike  this  in  princi- 
ple is  circumduction.  In  the  latter,  if  the  knee  is  moved  in  a 
small  circle,  the  head  will  move  in  a  small  circle ;  but  if  the  knee 


THE  NOMENCLATURE  OF  DISLOCATIONS  OF  THE  HIP.     113 

be  made  to  take  a  large  sweep,  then  the  head  will  take  a  cor- 
respondingly large  sweep,  since  it  (the  head)  has  a  radius  of  the 
entire  length  of  the  ilio-femoral  ligament  plus  the  length  of  the  neck 
of  the  femur.     Such  a  sweep  is  most  unnecessary  and  hazardous. 

Fig.  102. 


Unnecessary,  because  it  drives  the  head  away  from,  rather  than 
approximates  it  to,  the  socket.  Hazardous,  for  it  endangers  the 
sciatic  nerve  and  the  femoral  vessels. 


THE  XOMEXCLATURE  OF  DISLOCATIOXS  OF  THE  HIP. 


There  can  be  but  one  reason  for  assigning  a  name  to  a  disloca- 
tion, and  that  is,  that  it  furnishes  the  key  to  its  restoration. 

Surgeons  formerly  believed  that  all  parts  of  the  capsule  were 
equally  vulnerable,  and  that  the  head  passed  direct  to  its  destina- 
tion :  hence  as  many  varieties  of  dislocations  as  there  are  points  to 
the  compass. 

Formerly  it  was  universally  believed  that  in  the  muscles  lay  the 
principal  obstacle  to  replacement:  hence  depressants,  depletives,  and 
powerful  mechanical  appliances. 

8 


114 


INTRODUCTORY  STUDY. 


To-day  the  surgeon  believes 

That  the  muscles  are  passive  and  play  no  active  role  as  obstacles 
to  reduction ; 

That  after  dislocation  a  portion  of  the  capsule  still  connects  the 
femur  with  the  socket ; 

That  all  dislocations  must  be  reduced  with  a  distinct  recognition 
of  the  surviving  portion  of  the  capsule  ; 

And  that  most  dislocations  can  be  restored  by  unaided  manual 
effort. 

The  radical  universal  change  in  the  method  of  reduction,  logically 
interpreted,  implies  a  radical  universal  change  of  theory  in  the  mech- 
anism of  dislocations.  Whoever  flexes  a  femur  as  the  initial  step 
in  reduction  declares  by  so  doing  his  abandonment  of  former  theories 
and  his  acceptance  of  others  diametrically  opposite.  Hence  the 
question  irresistibly  follows.  Why  persist  in  a  nomenclature  that  was 
based  on  ignorance,  has  been  proven  to  be  false,  and  whose  retention 
can  lead  only  to  bewilderment  and  confusion  ?  Why  should  sur- 
geons retain  thyroid,  perineal,  pubic,  and  subspinous  varieties  of  dis- 
location of  the  hip  when  one  name  would  do  for  all,  and  the  same 
rule  for  their  reduction  ?  Physicians  may  with  equal  propriety 
describe  facial,  colic,  thoracic,  and  abdominal  measles. 


Fig.  103. 


Fig.  104. 


Fig.  105. 


Thyroid.   (Bigelow.) 


Pubic.  (Bigelow. 


Subspinous.  (Bigelow.) 


When  Bigelow  illustrated  his  memorable  monograph  upon  The 
Hip  he  dissected  a  part,  and,  placing  it  in  one  position,  his  artist 
photographed  a  thyroid ;  then  shifting  it  a  little,  the  artist  photo- 


IHE  NOMENCLATURE  OF  DISLOCATIONS  OF  THE  HIP.     115 

graphed  a  pubic ;  and  then,  by  a  further  slight  change,  the  prepara- 
tion was  posed  for  a  subspinous.  Why,  while  the  author  was  arguing 
for  the  supremacy  of  his  Y-ligament ;  why,  when  he  was  so  elo- 
quently demonstrating  that  the  various  signs  of  dislocation  were  all 
dependent  upon  the  remnant  of  capsule  that  still  bound  the  neck  of 
the  femur  to  the  pelvis ;  why,  I  ask,  did  he  not  with  one  stroke  of 
his  trenchant  pen  blot  out  the  whole  list  of  subtle  and  meaningless 
refinements,  and  unburden  the  memory  of  the  student  as  he  had 
unburdened  the  closets  of  the  surgeon  and  banished  the  cogwheels, 
screws,  ropes,  and  pulleys  from  the  domain  of  surgery  ?  Why  ? 
There  is  but  one  answer,  and  that  is,  that  it  never  occurred  to  him 


Fig.  106. 


Fig.  107. 


Head  in  socket.    (Bigelow.) 


Dorsum  ilii.    Mortise  rotated 
inward  90°.    (Bigelow.) 


that  variety  in  dislocations  was  brought  about  in  the  precise  manner 
in  which  lie  was  illustrating  it ;  that  every  variety  of  dislocation 
inward  must  have  been  primarily  into  the  thyroid  depression.  In 
the  formation  of  a  pubic,  how  could  the  head  reach  this  spot  without 
first  being  for  an  instant  at  least  a  thyroid  ;  and  how,  in  the  mechan- 
ism of  reduction,  can  a  pubic  be  restored  save  through  the  gateway 
of  the  thyroid  depression  ?  Again,  I  ask  in  all  candor,  after  the 
specimen  (Fig.  106)  was  placed  in  position  to  show  normal  relations, 
was  it  converted  into  the  high  dorsal,  as  represented  in  Fig.  107, 
hy  an  upivard  thrust,  even  though  every  part  of  the  capsule  had 
been  removed  except  the  Y-ligament?  or  was  the  femur  flexed  and 


116  INTR  OD  UOTOR  Y  STUB  Y. 

the  head  dislodged  at  a  low  point,  and  a  low  dorsal  converted  into  a 
high  one  ?     The  latter  unquestionably. 

If  it  be  urged  that  what  I  am  arguing  for  is  a  dissecting-room 
theory,  my  answer  is  that  it  is  the  very  dissecting-room  theory  that 
has  revolutionized  the  whole  subject  of  reduction  of  dislocations  ;  but 
when  I  turn  upon  my  objector  and  ask  him  what  his  theory  of  direct 
displacement  is  founded  upon,  he  can  only  reply,  theory ;  and  when 
I  ask  what  the  logical  result  of  such  a  theory  has  been,  he  can  only 
reply  by  pointing  to  a  most  humiliating  chapter  in  the  history  of 
modern  surgery. 

Were  I  to  suggest  a  nomenclature  for  dislocations  of  the  hip  I 
would  base  my  action  upon  the  firm  conviction  that  all  conceivable 
dislocations  are  primarily  either  inward  or  outward,  and  that  from 
these  primary  positions  the  head  may  be  secondarily  shifted  to  any 
point  about  the  socket  within  reach  of  the  remnant  of  untorn  capsule 
that  binds  the  shaft  to  the  rim  above  the  socket.  The  primary 
inward  I  would  denominate  thyroid ;  the  primary  outward,  dorsal. 
My  classification  then  would  be  : 

Low  thyroid,  ^  All  present  the  same  general  charac- 
Mid.  thyroid,  V  teristics,  viz.,  abduction  and  rotation 
High  thyroid.  J  outward. 

Reversed  thyroid  (Fig.  84). 

Low  dorsal,  ^  All  present  the  same  general  charac- 
Mid.  dorsal,  V  teristics,  viz.,  adduction  and  rotation 
High  dorsal.   J  inward. 

Reversed  dorsal  (Fig.  128). 

I  would  reject  the  names  "sciatic,"  "spinous,"  "interspinous," 
and  "  subspinous,"  as  I  do  not  think  they  stand  for  distinct  varieties 
of  dislocations.  As  the  head  can  closely  approximate  positions  de- 
scribed by  authors  as  "subspinous,"  "interspinous,"  or  "spinous  " 
from  either  plane,  if  the  names  are  to  be  retained,  I  would  suggest 
the  prefix  thyro  or  dorso.  AVe  would  then  have  thyro-spinous,  etc., 
if  the  head  reached  the  position  from  the  inner  plane,  and  dorso- 
spinous,  etc.,  if  from  the  outer  plane.  By  such  terms  the  mechanism 
of  dislocation,  diagnosis,  and  method  of  restoration  would  become 
inseparably  associated  with  the  injuries.  Preferably  I  would  say 
reversed  thyroid  and  reversed  dorsal,  as  given  in  the  classification. 


PART  II. 

REDUCTION  OF  DISLOCATIONS 

BT 

MANIPULATION. 


METHODS  AND  OBSTACLES  CRITICALLY  EXAMINED. 


REDUCTION   OF  DISLOCATIONS 

BY 

MANIPULATION. 


That  which  follows  upon  the  reduction  of  dislocations  is  based 
wholly  upon  the  assumption  that  all  dislocations  may  be  classified 
under  two  general  heads,  viz.,  Internal  and  External.  If  the  reader 
is  not  willing  to  accept  this  statement  as  a  matter  oi  fact,  I  ask  him 
to  do  so  on  the  ground  of  the  strongest  -pr  oh  ability . 

In  the  mechanism  of  all  dislocations  three  distinct  steps  must  be 
recognized  :  ^ 

1.  The  laceration  of  the  capsule ; 

2.  The  escape  of  the  head  from  the  confines  of  the  socket ; 

3.  The  shifting  of  the  head  from  the  position  it  occupied  at  the 
instant  of  escape  to  its  final  destination. 

It  is  important  that  these  steps  be  accepted  as  final ;  that  they  be 
regarded  as  axioms,  for  upon  them  I  base  the  time-honored  proposi- 
tion that  every  dislocation  must  he  restored  through  steps  in  the 
reverse  order  of  its  displacement.  If  there  is  a  first,  second,  and 
third  step  in  the  order  of  displacement,  then,  in  the  order  of  restora- 
tion, the  first  step  retraced  should  be  the  last  step  of  displacement, 
the  second  step  retraced  should  be  the  second  step  of  displacement, 
and  the  third  and  last  step  to  be  retraced  should  be  the  first  or 
initiatory  step  of  displacement.     I  shall  begin  with 

"  DISLOCATION  INWAKD. 

Reduction  by  traction — direct  method — Method  I. 

First  step.  Retrace  the  last  step  in  the  order  of  displacement ; 
locate  the  head  and  hring  it  hack  to  the  position  it  occupied  at  the 
instant  of  its  escape  from  the  socket. 

1  For  the  demonstratiou  of  these  steps,  see  p.  80. 


120    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

This  will  usually  be  easily  accomplished.  The  flexion,  abduction, 
and  rotation  outward  may  all  be  characteristically  present,  indicating 
that  the  head  lies  in  the  thyroid  depression,  with  the  great  trochanter 
in  the  region  of  the  socket.  (Fig.  78,  p.  92.)  Should  the  head  lie  upon 
or  above  the  ramus  of  the  pubes,  upon  the  pubes,  or  in  the  perineum, 
it  must  be  apparent  that  traction  in  the  long  axis  of  the  femur  and 
directed  toward  the  socket  is  indicated  as  the  proper  means  for  the 
retracement  of  the  last  step  of  displacement. 

But  if  the  last  step  of  displacement  was  accomplished  by  external 
rotation,  with  extension  of  the  femur,  the  unspent  force  continuing 
after  displacement  will  be  controlled  and  guided  by  the  remnant  of 
capsule  that  has  escaped  laceration.  It  is  thus  possible  to  have 
several  distinct  degrees  of  rotation  that  might  give  rise  to  as  many 
named  varieties,  but  all  be  the  same  in  principle.  From  a  disloca- 
tion inward  with  scarcely  any  noticeable  increase  of  rotation  outward, 
the  rotation  outward  may  be  so  great  that  the  toes  point  backward^ 
and  the  inside  of  the  foot  look  outward.  From  the  usual  position 
in  which  the  ilio-femoral  ligament  lies  upon  the  anterior  surface  of 
the  neck  (Fig.  108)  it  may  be  so  rotated  as  to  lie  behind  it  (Fig.  1 10). 
It  must  be  plain,  therefore,  that  in  order  to  retrace  the  last  step 
of  displacement  the  operator  should  first  distinctly  locate  the  head, 
notice  the  degree  of  constraint,  the  direction  of  the  long  axis  of  the 

'  I.  K.,  a  flabby-looking  man,  rather  fat,  was  admitted  into  Guy's  Hospital,  December  10, 
1835.  About  one  hour  before  his  admission  he  was  helping  to  carry  a  heavy  crate  down 
stairs,  when  his  foot  slipped  and  he  fell  backward,  receiving  the  weight  on  the  groin. 
The  following  are  the  appearances  which  the  limb  presented  as  he  lay  extended  on  his 
back  :  The  left  leg  was  shortened  at  least  two  inches  and  the  foot  excessively  everted  so  as 
almost  to  give  the  toes  a  direction  backward.  [Had  the  patient  been  erect  the  turning  back- 
ward would  not  have  been  interfered  with. — Author.]  The  injured  limb  had  a  tendency 
to  cross  the  sound  one,  so  as  to  throw  the  heel  of  the  former  over  the  instep  of  the  latter ; 
nevertheless  when  the  limbs  were  placed  side  by  side  they  remained  in  that  position. 
The  leg  was  susceptible  of  all  the  natural  motions  to  some  extent  with  the  exception  of 
rotation,  but  the  man  complained  of  great  pain  while  under  examination.  The  projection 
of  the  trochanter  major  was  entirely  lost,  whilst  the  luxated  head  of  the  bone  could  be  felt 
under  Poupart's  ligament,  just  below  and  to  thp  inner  side  of  the  anterior  superior  spinous 
process  of  the  ilium,  and  apparently  lying  between  the  anterior  inferior  spinous  process  of 
the  ihura  and  the  junction  of  that  bone  with  the  pubes.  It  thus  nested  on  the  brim  of  the 
pelvis  and  projected  upward  to  the  abdomen.  The  femoral  artery  was  not  displaced,  but 
could  be  traced  on  the  inner  side  of  the  dislocated  bone.  Reduction  :  Extension  was  made 
downward  by  means  of  a  jack-towel  about  the  knee  by  three  students,  while  Mr.  Morgan, 
sitting  in  the  bed,  made  counter-extension  with  his  foot  in  the  perineum.  After  three  min- 
utes the  man  was  told  to  raise  his  shoulders  from  the  bed,  at  which  time  forcible  rotation 
inward  accomplished  the  reduction  with  a  snap. — Cooj)er  on  Dislocjitions,  p.  124. 

Bigelow  quotes  this  case  under  everted  dorsal.'  but,  I  think,  incorrectly.  The  signs  are 
those  of  a  reversed  thyroid,  while  the  reduction  by  extension  and  rotation  inward  could  not 
reduce  an  everted  dorsal,  but  would  have  been  the  correct  manipulation  for  a  shifted 
thyroid. 

1  The  Hip,  by  Henry  J.  Bigelow.  y.  101. 


DISLOCATION  INWARD. 


121 


shaft,  the  degree  of  rotation  as  indicated  in  the  foot.  In  one  instance 
simple  flexion  will  retrace  the  last  step,  in  another  traction  in  the 
long  axis  of  the  shaft,  while  if  the  displacement  in  the  last  step  has 


Fig.  108. 


Fig.  109, 


Fig.  110. 


Y-ligament  in  front 
of  the  neck. 


Y-ligament  to  the  outer 
side  of  the  neck. 


Y-ligament  behind 
the  neck. 


taken  place  through  adduction,  extension,  and  external  rotation, 
then  flexion,  abduction,  and  internal  rotation  would  conduct  the 
head  to  the  position  it  occupied  at  the  completion  of  the  second 
step  of  displacement. 


Fig.  111. 


Fig.  112. 


Having  retraced  the  last  step  of  dislocation,  viz.,  the  shiftino-  of 
the  head  to  a  remote  position,  the  next  question  to  ask  is,  In  what 
'position  luas  the  shaft  the  instant  the  head  left  the  socket  ?  Answer. 
The  shaft  was  in  a  state  of  abduction  at  right  angles  to  the  trunk ; 
and  this  is  true,  whether  an  instant  later  it  was  succeeded  bv  ex- 


122    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

ternal  rotation  or  not.  To  produce  a  dislocation  inward  the  capsule 
must  be  put  upon  the  stretch  by  means  of  abduction,  and  when,  an 
instant  later,  the  head  has  sprung  from  the  socket  and  lies  in  the 
thyroid  depression,  the  shaft  is  still  in  a  state  of  abduction.  It 
must  be  plain,  therefore,  that  as  the  head  took  the  direction  from 
without  inward  while  the  femur  was  abducted,  the  thigh  should  be 
drawn  outward  in  the  long  axis  of  the  shaft  to  retrace  the  second 
step  of  dislocation.     In  retracing  this  step  it  must  be  borne  in 


Fig.  113. 


mind  that  the  trochanter  or  head  may  be  caught  upon  some  of  the 
bony  irregularities  of  the  socket  or  otherwise  entangled.  Hence, 
in  making  traction  outward  accompany  it,  if  the  head  or  shaft 
seems  caught,  with  collateral  movements,  as  slight  rotation  or  rock- 
ing— i,  e.,  be  sure  that  with  traction  the  head  leaves  the  thyroid 
depression  and  takes  its  position  over  or  near  the  socket. 

The  second  step  has  been  retraced — i.  e.,  the  head  has  been  placed 
over  the  socket.  Query.  Why  will  not  simple  traction  outward 
place  the  head  in  the  socket  ?  Answer.  The  effect  of  traction  out- 
ward is  to  make  tense  the  remnant  of  untorn  capsule  ;  but  when  this 
is  tense  through  traction  outward,  the  shaft  and  the  two  attachments 
of  the  remnant  are  in  the  same  line,  and  as  the  head  stands  oflF  from 
the  shaft  at  an  angle  of  130°,  it  is  plain  that  traction  outward  can 
only  bring  the  head  to  a  position  over  the  socket,  but  cannot  possi- 
bly replace  it  in  the  socket.  To  do  this  a  new  element  must  be 
invoked,  viz.,  direct  pressure.  But  direct  pressure  alone  is  not  the 
reverse  of  the  initial  step  of  displacement,  in  that  the  shaft  was 
descending  as  the  head  burst  through  the  capsule ;  hence,  to  accom- 


DISLOCATION  INWARD. 


123 


plish  the  last  step,  elevate  the  knee,  while  an  assistant  makes  direct 
pressure  upon  the  head.     (Fig.  115.)      Query.  Why  will  not  simply 


Fig.  114. 


Fig.  115. 


elevating  the  knee  replace  the  head  ?  Answer.  Because  it  is  totally 
unlike  the  first  steps  of  displacement.  In  this,  as  the  shaft  descended, 
the  neck  of  the  femur  pressing  on  the  rim  of  the  socket  (Fig.  116) 


Fig.  116. 


had  a  bony  fulcrum,  which  forced  the  head  out  of  the  socket.  In  the 
act  of  replacement  the  simple  act  of  elevating  the  knee  encounters  no 
corresponding  fulcrum  to  force  the  head  downward  as  the  knee  rises. 
The  necessary  traction  to  bring  the  head  over  the  socket  has  also  com- 
pelled the  head  to  rise  above  the  level  of  the  socket,  and  as  traction, 
to  hold  the  head  over  the  socket,  must  be  accompanied  with  the 
elevation  of  the  knee,  we  are  compelled  to  invoke  a  new  element, 
viz.,  direct  pressure  to  replace  the  head. 

For  the  replacement  of  the  head  by  direct  steps  I  oifer  the  follow- 
ing directions : 

1.  Flex  and  abduct  the  femur. 


124    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

2.  Make  traction  outward. 

3.  Fix  the  head  by  digital  pressure  and  adduct. 

The  medical  profession  has  long  practised  with  variable  success 
methods  somewhat  resembling  that  which  has  just  been  described. 
Authors  recommend : 

1.  To  flex  and  adduct  the  thigh. 

2.  To  make  perpendicular  traction  upon  the  knee,  and  follow 
traction  by  adduction. 

3.  To  make  traction  with  adduction,  using  the  foot  in  the  groin 
as  a  fulcrum. 

4.  To  place  the  patient  astride  a  bed-post,  using  it  as  a  fulcrum 
while  extension  and  adduction  are  made. 

5.  To  make  traction  and  adduction  while  an  assistant  with  a  fillet 
passed  between  the  thighs  makes  traction  obliquely  upward  and 
outward. 

All  of  these  have  been  recommended,  but  success  in  their  employ- 
ment does  not  depend  upon  the  scientific  application  of  the  principle. 
In  all  adduction  is  made  a  prominent  feature ;  but 
adduction,  if  attempted  too  early,  defeats  its  own 
end.  This  can  best  be  illustrated  by  means  of  a 
diagram.  In  this,  Fig.  117,  adduction  inward 
makes  tense  the  remnant  of  untorn  capsule,  which 
acts  as  a  fulcrum,  about  which  both  arms  of  the 
lever  revolve.  As  the  long  arm  is  carried  inward 
the  short  arm,  head,  and  neck  must  move  outward. 
This  is  impossible  under  the  circumstances,  be- 
cause the  tense  ligament  drives  the  head  against 
the  rim  or  into  the  thyroid  depression.  From 
this  it  will  be  seen  that  the  obstacle  in  this 
case  is  created  by  the  operator,  who  adducts 
before  he  has  made  traction  outward.  It  illustrates  strikingly  the 
folly  of  violence  or  brute  force. 

I  have  entered  into  minute  details  in  describing  the  direct  method 
of  reduction,  because  it  is  the  only  method  in  which  every  step  is 
retraced.  I  may  be  going  too  far  when  I  say  that  it  is  the  safest, 
surest,  and  only  rational  method.  By  means  of  it  in  one  of  my 
experimental  studies  I  reduced  the  head  readily  many  times  in  suc- 
cession from  a  dislocation  inward,  but  when  I  resorted  to  rotation 
I  encountered  obstacles  that  could   only  be  overcome  by  further 


DISLOCATION  INWARD.  125 

laceration  of  the  rent  in  the  capsule — a  most  unnecessary  expedient 
when  replacement  was  jjossible  tvithout  it,  and  a  most  dangerous 
expedient  token  by  enlargement  of  the  rent  through  circumduction 
and  rotation  the  capsule  is  dissected  from  the  rent  in  the  muscles  and 
placed  in  such  a  condition  that  it  is  possible  to  drive  some  portion 
of  it  before  the  head  into  the  socket,  and  render  a  clean  and  abso- 
lutely perfect  reduction  impossible. 

Indirect  Method — Reduction  by  Rotation. 

The  method  just  described  I  designate  the  direct  method.  There 
is  another  in  which  rotation  forms  a  prominent  feature,  and  which 
may  properly  be  denominated  the  indirect  method.  Rotation  may 
or  may  not  be  associated  with  abduction  during  the  first  and  second 
steps  of  dislocation  inward.  The  rotation  recommended  to  effect 
restoration  is  not  employed  to  make  the  head  retrace  its  steps  on 
the  principle  that  it  is  the  reverse  of  the  agency  that  caused  the 
displacement.  Its  efficacy  is  entirely  foreign  to  the  laws  of  dis- 
location, and  rests  for  its  means  of  success  upon  the  utilization  of 
the  Y-ligament,  i.  e.,  the  remnant  of  untorn  capsule.  By  the 
proper  employment  of  the  femur  as  a  lever  this  ligament  becomes 
a  fulcrum  and  can  be  often  used  to  great  advantage. 

We  employ  two  varieties  of  rotation,  viz.,  external  and  internal. 

Reduction  by  means  of  external  rotation — Method  II. 

First  step.  Flex  the  thigh,  but  not  to  a  perpendicular. 

Second  step.  Adduct,  carrying  the  knee  obliquely  inward  and 
downward. 

Third  step.  Rotate  outward. 

The  object  of  the  fi.rst  step  is  to  bring  the  head  into  the  position 
it  occupied  the  instant  it  passed  the  confines  of  the  socket.  If  the 
head  lies  upon  the  pubes,  in  the  perineum  or  above  the  socket,  as 
pointed  out  in  the  first  method,  then  simple  flexion  will  not  effect 
retracement,  but  other  means  must  be  employed  to  do  so.  Suffice  it 
to  say  that  no  second  step  is  to  be  considered  until  the  first  step  is 
taken.  In  flexing  the  femur  the  operator  is  cautioned  not  to  flex  to 
a  perpendicular.  The  reason  for  the  caution  is  that  such  a  degree 
of  flexion  tends  to  carry  the  head  away  from  the  socket  and  cause  it 
to  sink  deeper  into  the  thyroid  depression. 

We  are  now  ready  for  the  second  step,  viz.,  "adduct  and  carry 
the  knee  obliquely  inward  and  downward.".    Observe  the  position 


126    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

of  the  head  :  it  lies  below  and  internal  to  the  socket.  The  remnant 
of  untorn  capsule,  which  is  to  conduct  the  head  back  home,  is  at- 
tached above  the  socket.  When  the  knee  is  vertical  or  slightly 
abducted  this  remnant  is  relaxed,  but  the  instant  the  knee  is 
adducted  and  directed  obliquely  inward  and  downward  the  rem- 
nant of  capsule  becomes  tense  and  inclines  to  draw  the  head  upward 
and  outward.  To  facilitate  this,  the  third  manoeuvre  in  the  method 
is  resorted  to — viz.,  rotation  outward,  i.  e.,  turning  the  ankle  of  the 
bent  leg  inward  and  upward.     (Fig.  118.) 

Fig.  118. 


The  head  of  the  femur  has  been  brought  to  the  border  of  the  socket ;  the  femur  is  abducted, 
but  not  so  much  as  is  represented  in  the  figure.  The  femur  must  be  rotated  outward  by 
means  of  the  bent  leg,  which  is  turned  inward  as  a  crank;  this  makes  taut  the  outer  border 
of  the  remnant  of  capsule,  /.  e.,  the  outer  band  of  the  Y-ligament. 

The  operator  must  not  regard  adduction,  extension,  and  rotation 
outward  as  distinct  and  separable  movements ;  on  the  contrary,  it  is 
the  happy  blending  of  the  three  that  invites  success.  With  the  patient 
lying  flat  on  the  floor  and  the  femur  flexed,  the  operator  places  his 
bent  elbow  beneath  the  flexed  knee  and  grasps  the  ankle  with  the 
unoccupied  hand ;  he  then  extends,^  adducts,  and  rotates  outward 
({.  e.,  carries  the  bent  leg  inward),  the  combined  movements  some- 
■  times  advantageously  accompanied  with  a  gentle  spring.    I  have  em- 


1  Extension  is  the  reverse  of  flexion,  and  can  be  accomplished  with  the  bent  elbow  beneath 
the  knee.  By  this  means  traction  in  the  long  axis  of  the  shaft  can  be  combined  with  exten- 
sion, and  is  never  to  be  omitted. 


DISLOCATION  INWARD. 


127 


ployed  this  method  with  gratifying  success,  both  in  experimental  and 
clinical  work.  In  the  case  of  a  young  adult  who,  from  faulty  diag- 
nosis, had  an  unreduced  thyroid  dislocation,  associated  with  fracture 
in  the  upper  third  of  the  femur,  the  head  was  easily  restored  eight 
weeks  after  the  original  accident  by  the  method  described. 

Obstacles.  In  dislocations  inward  the  pubo-femoral  ligament  (Fig. 
119)  often  escapes  uninjured.     Now  if  the  head  is  to  be  returned,  it 


Fig.  119. 


Dislocation  into  the  thyroid  depression.    The  great  trochanter  rests  against— i.  e.,  is  caught 
upon— the  rim  of  the  socket.    The  head  is  partly  covered  by  the  pubo-femoral  ligament. 

must  pass  beneath  this  band.  If  adduction  be  made  too  obliquely 
downward  and  inward,  or  if  external  rotation  be  too  early  attempted, 
the  head  will  strike  against  this  band  and  be  prevented  from  enter- 
ing the  socket,  or  the  head  may  pass  above  the  band  and  ascend 
toward  the  horizontal  ramus  of  the  pubes.  To  avoid  such  a  con- 
tingency the  knee  should  be  elevated  approaching  the  perpendicular, 
and  by  combining  adduction  with  rotation  the  reduction  may  often  be 
readily  accomplished.  The  degree  of  adduction  will  vary  with  the 
length  and  amount  of  the  remnant  of  capsule.  Whatever  be  the 
nature  of  the  obstacle  it  should  not  be  essayed  by  violence.     Vio- 


128     REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

lence  masks  the  nature  and  position  of  the  obstacle  which  gentler 
measures  may  detect  and  skill  overcome. 

Reduction  by  Means  of  Rotation  Inward — Method  III.  Bige- 
low  puts  this  manoeuvre  at  the  head  of  his  ten  rules.  His  directions 
are :  "  Flex  the  limb  toward  the  perpendicular  and  abduct  a  little 
to  disengage  it  from  the  bone,  then  rotate  the  thigh  strongly  inward, 
adducting  it  and  carrying  the  knee  to  the  floor.  The  trochanter  is 
then  fixed  by  the  Y-ligament  and  the  obturator  muscle,  which  serve  as 
a  fulcrum.  While  these  are  wound  up  and  shortened  by  rotation  the 
descending  knee  pries  the  head  upward  and  outward  to  the  socket."' 
Bigelow  makes  no  reference  to  clinical  support  of  this  method,  and 
I  am  inclined  to  believe  that  his  confidence  in  it  rests  entirely  upon 
experimental  work.  I  have  been  delighted  with  it  in  certain  ex- 
perimental cases  and  disappointed  with  it  in  others.  I  have  failed 
with  it  in  clinical  trials.  For  the  purpose  of  a  critical  study  I  shall 
divide  the  method  into  three  steps : 

JRule. — First  step.  Flex  the  thigh,  but  not  to  a  perpendicular. 

Second  step.  Rotate  strongly  inward. 

Third  step.  Adduct  and  carry  knee  to  the  floor. 

The  first  step  is  identical  with  the  preceding  and  needs  no  added 
comment. 

Second  step — i.  e.,  "rotate  strongly  inward."  By  this  manoeuvre 
the  head  is  carried  to  the  deepest  part  of  the  thyroid  depression. 
Now  just  at  the  instant  when  the  head  is  fixed  (i.  e.,  wound  up  by 
the  tense  ligament)  Bigelow  directs  that  the  knee  be  suddenly  and 
strongly  adducted  with  a  view  to  prying  the  head  over  the  acetab- 
ular rim  into  the  socket.  In  executing  it  the  operator  must  not 
separate  "  rotation  inward  "  from  "adduction  and  prying  downward 
and  inward."  The  three  distinct  manoeuvres  must  be  combined  in  a 
single  eflfort :  with  one  hand^  grasping  and  controlling  the  knee,  the 

1  Henry  J.  Bigelow  :  The  Hip,  p.  77. 

Sir  Astley  Cooper,  in  dislocations  inward,  combined  rotation  inward  with  the  pulleys. 
Bramsby  Cooper,  his  nephew,  fully  believing  that  the  only  resistance  to  reduction  lay  in  the 
muscles,  thus  explain.^  the  advantage  of  rotation  inward  :  "  Rotation  inward  elevates  the 
trochanter  major  and  thereby  places  it  in  the  most  favorable  position  for  the  gluteus  meJius 
and  minimus  to  draw  the  head  of  the  bone  toward  the  acetabulum."  This  statement  ap- 
pears in  Guy's  Hosp.  Rep.,  1X36,  vol.  i.,  just  twelve  years  before  Morton,  by  the  introduction 
of  anaesthesia,  struck  the  death-blow  to  the  theory  of  muscular  assistance  or  resistance. 

-  I  feel  that  I  cannot  too  often  alluae  to  the  danger  of  grasping  and  controlling  the  knee 
Avith  the  hand.  An  insensible  or  voluntary  pressure  upon  the  knee  accompanies  this  con- 
trol, which  drives  the  head  downward  upon  anything  with  which  it  comes  in  contact.  The 
safest  control  is  through  traction  with  the  bent  elbow  beneath  the  bent  knee. 


DISLOCATION  INWARD. 


129 


other  grasping  the  ankle,  the  knee  is  directed  inward  and  downward, 
while  the  ankle  is  turned  outward  and  upward,  the  combined  action 
resembling  in  some  measure  the  movement  of  boring  with  an  auger, 
in  which  both  hands  seem  to  move  in  opposite  directions. 

There  are  objections  to  this  method  which  the  operator  should 
understand,  for  if  properly  appreciated  it  will  not  be  persevered  in 
beyond  a  fair  trial.  The  rotation  is  inivard.  The  object  of  this  is 
to  bring  the  head  directly  beneath  the  fulcrum,  viz.,  the  Y-ligament,^ 


Fig.  120. 


Femur  adducted':  rotation  of  the  femur  inward,  accomplished  by  turning  the  bent  leg, 
as  a  crank,  outward.  Notice  that  the  socket,  head,  capsule,  and  shaft  lie  in  the  same 
direction. 

SO  that  when  the  knee  is  adducted  and  pried  inward  and  downward 
the  head  will  be  pried  upward  and  outward.  Note,  however,  that 
while  rotation  inward  brings  the  head  beneath  the  fulcrum,  it  also 
brings  the  head  into  the  deepest  part  of  the  thyroid  depression,  a 
condition  at  times  very  obstructive  and  unfavorable  to  reduction. 

In  some  experimental  work  I  have  met  with  obstacles  which  could 
be  overcome,  in  others  I  have  failed,  and  I  am  inclined  to  the  belief 
that  the  acetabular  rim  is  more  prominent  and  insurmountable  in 
some  cases  than  in  others.  When  in  some  cases  I  have  used  force, 
as  Bigelow  directs,  I  have  brought  the  head  so  strongly  against  the 
rim  of  the  acetabulum  as  to  denude  it  (the  rim)  of  periosteum  and 
tear  the  cotyloid  cartilage  from  its  attachment ;  and  when  I  have 
persevered  I  have  felt  the  head  grate  upon  the  denuded  rim,  and 
upon  examination  have  found  the  cartilaginous  covering  of  the  head 


1  See  p.  130,  foot-note. 
9 


130     RED  UCTION  OF  DISL  0  CA  TIONS  B  Y  MA  NIP  ULA  TION. 

deeply  scored  when  it  had  been  forced  against  the  naked  rim  of  the 
socket. 

A  second  defect  in  this  method  is  that  rotation  inward  often  con- 
veys the  head  outward,  thus  suddenly  and  unintentionally  converting 
a  thyroid  into  a  dorsal  dislocation.  It  is  to  avoid  this  that  Bigelow 
recommends  "strong  rotation  inward,"  holding  the  knee  and  ankle 
well  under  command,  lest  it  dodge  at  the  critical  moment.  That  it 
is  likely  to  do  so  may  be  learned  from  the  fact  that  the  head  is  round 
and  covered  with  a  smooth  and  slippery  cartilage,  while  the  periphery 
of  the  socket  is  crowning  and  not  calculated  to  give  a  very  stable 
support  to  anything  pressed  against  it.  Indeed,  the  probability  of 
the  head  going  into  the  socket  is  far  less  than  that  it  slip  to  the  right 
or  left  of  it. 

I  have  failed  clinically  in  two  instances  by  this  method,  and 
though  in  each  I  failed  with  other  methods,  the  fact  of  failure  is  an 
argument  that  it  does  not  possess  special  superiority.  Since  the 
memorable  treatise  of  BigeloAv,  in  1869,  this  method  has  had  a  fair 
and  impartial  trial,  and  the  verdict  of  the  profession  is  in  favor  of 
rotation  outward,  i.  e.,  the  first  method  of  rotation. 

In  the  opening  of  this  chapter  I  designated  the  first  method  by 

Fig.  121.1  Fig.  122. 


Figs.  121  and  122,  purely  diagrammatic,  introduced  to  illustrate  the  lever  and  fulcrum  (sling), 
and  how  in  one  case  (Fig.  122)  an  obstacle  may  be  overstepped  by  lifting  the  lever. 


>  While  the  capsule  acts  as  a  fulcrum,  it  is  not  in  this  case  a  pure  one  ;  its  function  is  rather 
that  of  a  sling.  If  the  sling  is  short,  depression  of  the  lever  will  drive  it  strongly  against  the 
obstruction.  (Fig.  121.)  I  would  therefore  suggest  that  the  operator,  when  he  gets  the  femur 
in  the  position  he  wishes  by  tirst  flexing,  then  rotating  inward  to  bring  the  head  obliquely 
below  the  socket,  and,  lastly,  adducting  a  little  to  feel  the  tension  of  the  sling  ;  that  instead 
of  sudden  and  powerful  depre.ssion  of  the  lever  he  substitute  a  sudden  jerk  upward  (Fig. 
122)  and  inward  to  lift  the  head  in  a  measure  over  the  rim,  and  combine  the  jerking  with 
sudden  depression. 


DISLOCATION  OUTWARD.  131 

traction  as  the  direct^  and  the  following  by  rotation  as  the  indirect, 
method.  Of  the  first  I  said  that  the  steps  in  reduction  were  the 
literal  retracement  of  the  steps  of  dislocation.  But  I  cannot  say  the 
same  thing  of  the  methods  by  rotation.  In  these  the  Y-ligament 
acts  as  a  fulcrum,  but  the  fulcrum,  instead  of  lying  beneath  the 
lever,  is  attached  above  it,  and  may  be  said  to  suspend  the  lever ; 
hence  when  the  end  of  the  long  arm  descends  the  end  of  the  short 
arm  is,  as  Bigelow  styles  it,  pried  out  of  the  thyroid  depression,  over 
the  rim,  and  into  the  socket. 

If  it  be  considered  a  cardinal  principle  in  all  efforts  at  reduction 
to  place  the  shaft  of  the  femur  in  the  respective  stages  of  displace- 
ment, then  the  first  method  (viz.,  by  traction)  meets  every  require- 
ment, while  that  by  rotation  violates  them.  In  the  method  by 
rotation  the  Y-ligament  as  an  agency  that  had  no  part  in  the  act 
of  dislocation  inward  is  invoked  to  participate  in  the  reduction,  and 
that  through  adduction  inward  and  downward,  a  force  in  no  Avay 
associated  in  the  mechanism  of  this  variety  of  dislocation. 


DISLOCATION^  OUTWAKD. 

First  step.  Retrace  the  last  step  in  the  order  of  displacement. 
Locate  the  head  and  bring  it  back  to  the  position  it  occupied  at  the 
terminatio7i  of  the  second  step  in  displacement. 

This  may  be  a  very  simple  thing.  The  dislocating  energy  may 
have  been  spent  in  the  second  stage  and  the  displacement  in  the 
third  stage  may  be  simply  due  to  the  unsupported  weight  of  the  leg, 
which  drags  the  femur,  and  it  inclines  downward  and  inward.  (Fig. 
123.)  In  such  a  case  the  operator  has  simply  to  elevate  the  knee 
to  a  perpendicular,  when  it  will  reassume  the  position  (see  Fig.  85) 
it  occupied  at  the  completion  of  the  second  step  of  dislocation. 
In  most  instances,  either  because  the  dislocating  energy  is  unex- 
pended after  rupture  of  the  capsule,  or  to  exti'aneous  causes,  such 
as  transportation  or  manipulation,  the  head  is  displaced  to  a  position 
remote  from  its  place  of  exit.  It  is  important  then  to  locate  it,  /.  e., 
study  how  it  reached  its  destination  and  make  it  retrace  its  own  path. 

I  have  repeatedly  stated  that  great  constraint  always  betokens  a 
minimum  degree  of  laceration  of  capsule,  and  the  reverse  of  this  is 
equally  true,  that  a  slight  degree  of  constraint  may  be  regarded  as 


132    RED  UCTIOX  OF  DISLOCA TIONS  B  Y  MANIP ULA TION. 

the  exponent  of  extensive  laceration  of  capsule.  Note  especially 
that  the  untorn  portion  of  capsule  that  acts  as  the  halter  of  the  dis- 
located head  and  neck  lies  on  the  inner  side.  This  remnant  of  cap- 
sule— the  ilio-femoral  ligament,  the  Y-ligament  of  Bigelow — is 
attached  to  the  lower  spine  above  the  socket  by  a  single  insertion  ; 
but  below  its  fibres  separate  into  two  bundles,  which  Bigelow  desig- 
nates the  outer  and  inner  bands  or  branches.     It  stands  to  reason, 


Fig.  123. 


therefore,  that  the  upper  spinous  attachments  must  be  as  strong  as 
the  two  combined  lower  attachments,  and  that  it  would  require 
double  the  force  to  rupture  the  upper  that  would  be  required  to  rup- 
ture either  of  the  lower  attachments,  providing  the  latter  are  of 
equal  size  and  length.  They  are  not  however  of  equal  length,  and 
after  dislocation  a  secondary  force  may  act  alone  upon  the  shorter 
outer  portion,  lacerating  some  of  its  fibres  or  completely  tearing  it 
from  its  attachment.  The  same  is  true  of  muscles.  If  the  head  has 
escaped  Avith  a  minimum  degree  of  laceration,  the  constraint  will  be 
marked,  but  when  the  obturator  internus  and  pyriformis  are  fully 
torn  the  restraint  will  be  greatly  diminished. 


DISLOCATION  OUTWARD. 


133 


The  head  may  then  lie  upon  the  dorsum  ilii,  the  whole  limb  may 
be  extended,  suffer  itself  to  be  rotated  outward,  and  still  exhibit 
nothing  more  than  the  freedom  permitted  by  an  extensive  laceration 
of  the  capsule  and  of  the  short  rotator  muscles.  In  all  such  cases 
traction  downward  will  bring  the  head  into  the  region  of  the  socket, 
when  flexion  will  place  the  femur  in  the  position  it  occupied  at  the 
close  of  the  second  step  of  dislocation. 

But  a  change  is  possible  that  should  be  understood.  The  original 
force,  which  was  that  of  rotation  inward,  may  be  reversed  after 
dislocation  takes  place,  and  the  third  step  of  dislocation  may  yield 
us  the  position  of 

Dorsal  "with  E version. 

There  is  nothing  in  this  condition  to  mystify  the  reader;  it  depends 
upon  physical  laws  and  is  easily  explained.     By  a  glance  at  Fig. 


Fig.  124. 


Fig.  125. 


Fig.  126. 


Fig.  124.— Inverted  dorsal ;  so-called  because  the  knee  is  turned  inward  and  the  foot  rotated 
inward.    In  this  the  head  turns  inward  and  rests  against  the  side  of  the  pelvis. 

Fig.  125.— Everted  dorsal ;  so-called  in  contradistinction  from  the  primary  or  first  condi- 
tion of  every  outward  dislocation,  whicli  is  dorsal  with  inversion.  In  dorsal  with  erersion  the 
foot  turns  out,  the  trochanter  (not  the  head)  rests  against  the  side  of  the  pelvis,  and  the  head 
looks  outward.  To  reduce  an  everted  dorsal  (Fig.  125),  it  must  be  first  converted  into  an 
inverted  dorsal  (Fig.  124). 

Fig.  126  is  only  a  shifted  position  from  Fig.  125. 


124  it  will  be  evident  that  rotation  outward  would  be  possible  by 
still  further   adductins:;   the   knee ;   or   if  the  femur  was  extended 


134    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

and  outward  rotation  instituted,  the  laceration  of  the  outer  branch 
of  the  Y-ligament  would  readily  liberate  the  head  and  permit  of 
eversion.  The  eversion  will  vary  in  degree  and  the  position  of  the 
head  will  vary!  The  foot  may  exhibit  normal  eversion  (Fig.  125), 
or  it  may  even  look  slightly  outward  and  backward  (Fig.  126). 
The  head  may  lie  against  the  dorsum  (Fig.  125),  or  it  may  rise  to  a 
level  with  the  anterior  border  of  the  ilium,  or  it  may  extend  over  the 
border^  its  neck  resting  on  the  interspinous  notch  (Fig.  126).  The 
critical  reader  has  not  failed  to  notice  a  striking  resemblance  between 
two  very  diverse  conditions,  viz.,  a  dislocation  primarily  inward  into 


Fig.  127. 


Fig.  128. 


Fig.  127.— Thyroid  reversed.  I  designate  this  a  tliyroid,  because  it  was  originally  a  tbyroid 
dislocation  (Fig.  78),  With  the  head  pointing  inward  and  the  foot  pointing  forward.  It  is 
reversed,  for  iiow  the  head  points  outward  and  the  foot  backward.  I  call  it  a  thyroid  re- 
versed, and  by  the  name  indicate  that  it  can  only  be  reduced  by  converting  it  into  a 
primitive  thyroid,  i.  e.,  into  a  dislocation  inward,  into  the  thyroid  depression.  For  the 
successive  steps  of  causation,  see  Figs.  78,  82,  83,  84. 

Fig.  128.— Dorsal  reversed  ;  so-called  in  contradistinction  from  the  primary  dorsal  disloca- 
tion, which  is  always  accompanied  with  inversion  of  the  foot  and  rotation  inward  of  the 
axis  of  the  shaft  of  the  femur.  The  reversed  dorsal  is  not  a  primary  or  original  dislocation  ; 
it  is  a  consecutive  or  secondary  change  from  an  original  inverted  dorsal.  For  its  reduction 
the  first  step  must  be  to  convert  an  everted  into  an  imerled  dorsal. 


the  thyroid  depression,  but  which  has  by  secondary  influence  been 
rotated  outward,  so  that  the  foot  points  outward  and  backward  (Fig. 
127),  and  another,  dislocated  primarily  outward,  but  which  by  re- 
versed action  also  yields  a  foot  turned  outward,  or  even  slightly 
backward  (Fig.  128). 


DISLOCATION  OUTWARD.  135 

As  these  two  conditions  are  the  result  of  forces  directly  opposed 
to  each  other,  and  that  for  their  reduction  they  will  require  equally 
diverse  methods,  must  be  apparent. 

The  diagnosis  between  these  two  conditions  is  a  very  difficult  one, 
a  statement  which  is  happily  illustrated  in  the  contradictory  views  of 
Sir  Astley  Cooper  and  Henry  J.  Bigelow,  the  former  of  whom  re- 
garded the  case  recorded  on  p.  120  as  "upward  and  forward,"  and 
the  latter  as  "  dorsal  with  eversion."  I  shall  not  attempt  to  lay  down 
any  rules  by  which  these  two  conditions  can  be  distinguished  ;  I  shall 
rather,  first,  show  their  general  resemblances,  and,  second,  offer  some 
general  points  of  divergence. 

(a)  In  neither  form  of  dislocation  ivill  there  he  evidence  of  de- 
cided fixation.  In  the  thyroid  reversed,  shifted  upward,  the 
Y-ligament  will  be  seen  (Fig.  127)  to  lie  under  (behind)  the 
neck.  Hence,  it  cannot  offer  any  constraint  except  against  traction. 
In  the  reversed  dorsal  (Fig.  128)  the  Y-ligament  lies  on  the  inner 
side  and  may  bind  the  head  and  neck  with  considerable  force,  but 
even  this  constraint  will  vary  with  the  integrity  of  the  outer  branch 
of  the  Y-ligament,  which  is  generally  torn  in  the  reversed  dorsal, 

(b)  In  neither  form  of  dislocation  luill  the  limb  refuse  to  lie  ^xir- 
allel  with  its  sound  fellow.  There  may  be  a  little  tendency  to  ad- 
duction, but  in  neither  case  will  the  limb  show  constraint  when 
placed  in  normal  extension  and  abduction.  There  are  three  condi- 
tions that  might  simulate  the  external  rotation  and  parallelism, 
VIZ.:  Fracture  of  the  neck  of  the  femur ;  reversed  dorsal ;  and  a 
reversed  thyroid.  Of  these  three  conditions  the  former  may  be  ex- 
cluded if  the  patient  is  able  to  sit  upon  a  chair.  In  such  a  posture 
the  fractured  thigh  would  show  shortening  by  comparison  of  the 
knees,  but  the  knees  would  look  forward ;  in  the  remaining  two, 
viz.,  in  the  dorsal  reversed  and  in  the  thyroid  reversed,  the  affected 
knees  would  look  outAvard  in  the  sitting  posture,  and  the  bent  leg, 
resting  on  the  toes,  would  lie  behind  its  fellow.     (Fig.  129.) 

Although  I  cannot  offer  positive  points  of  diagnosis,  I  will  call 
attention  to  the  followino- : 

(a)  Extreme  outward  rotation  in  which  the  inside  of  the  foot  tends 
to  look  outward — the  heel  forward  and  inward — is  hardly  possible  in 
any  condition  save  that  of  a  primary  dislocation  inward,  with  ex- 
ternal rotation,  the  head  being  controlled  by  the  Y-ligament,  which 
is  untorn.     The  outward  rotation  of  everted  dorsal  is  rarely  beyond 


136     REDUCTION  OF  DISLOCATIONS  BY  3IANIPULATI0N 

rectangular  eversion.  To  [determine  -whether  the  case  in  question  be 
an  everted  dorsal,  let  the  operator  make  a  gentle  attempt  to  rotate 
still  further  outward.     This  will  be  checked  because  the  Y-ligament 


Fig.  129. 


Fig.  130. 


Figs.  129, 130.  Everted  dorsal  dislocation  of  left  femur.  Originally  this  injury  was  an  in- 
verted dorsal.  The  accident  occurred  in  childhood,  and  was  caused  by  a  fall  from  a  ladder. 
The  limb  never  gave  any  (Kscomfort,  but  by  constant  use,  either  through  flattening  of  the 
head  of  the  femur,  the  deepening  of  the  artificial  socket,  or  the  lengthening  of  the  remnant 
of  untorn  capsule,  the  inverted  dorsal  gradually  became  a  well-marked  everted  dorsal.  The 
left,  or  injured,  limb  was  the  one  on  which  he  bore  his  weight  when  standing.  This  was 
owing  to  the  great  shortening  and  the  disparity  between  his  limbs.  It  will  be  observed  that 
in  sitting  the  left  limb  lies  back  of  the  right  and  rests  upon  the  toes.  If  the  reader  turn  to 
Figs.  125  and  126,  he  will  see  that  in  these  the  knees  look  outward,  and  in  them  in  the  sitting 
posture  the  inner  side  of  the  knee  would  look  forward. 


lies  in  front  (Fig.  128),  and  external  rotation  will  make  it  tense. 
Not  so  Avith  the  "  thyroid  reversed."  In  this  case  the  Y-ligament 
lies  behind  (Fig.  127),  and  rotation,  after  the  foot  looks  backward, 
can  still  be  increased. 


DISLOCATION  OUTWARD. 


137 


(b)  If  the  foot  looks  backward  or  outward,  find  the  head ;  to  do 
this  locate  the  inner  condyle  ;  it  points  in  nearly  the  same  direction 
as  the  neck.  After  this  locate  the  great  trochanter,  it  will  lie  inter- 
nal to  the  dividing  line  between  the  two  divisions  of  the  bone  (Fig. 
131,  X,  Y),  when  the  head  has  been  dislocated  primarily  inward; 
but  if  the  head  were  dislocated  primarily  outward,  the  trochanter 
major  cannot  lie  internal  to  this  line. 


Fig.  131. 


Lastly,  make  direct  pressure  upon  the  head ;  if  it  be  a  reversed 
dorsal,  the  head  Avill  sink  ;  if  a  shifted  thyroid,  the  upper  end  of  the 
femur  will  have  a  bony  support ;  if  it  be  a  dorsal  with  eversion  only, 
the  head  can  be  felt  by  direct  pressure ;  if  it  be  a  shifted  thyroid, 
the  trochanter  can  be  felt  as  well  as  the  head. 

It  must  be  evident,  therefore,  that  retracing  the  last  step  of  dis- 
location is  not  a  simple  or  unimportant  matter ;  that  a  confident 
rational  procedure  will  only  be  based  upon  a  knowledge  of  the  path 
taken  by  the  head.  As  we  are  now  dealing  with  dislocations  out- 
ward, the  first  thing  to  do  if  we  are  dealing  with  an  everted  dorsal, 
is  to  convert  it  into  an  "inverted  dorsal."  To  do  this,  flex  (this 
will  relax  the  Y-ligament),  abduct,  and  rotate  inward.  The  opera- 
tor should  observe  carefully  that  the  head  follows  the  manipulation ; 


138    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

if  it  does,  he  has  retraced  the  last  step  of  dislocation,  and  is  ready 
to  undertake  the  second  step. 

Fig.  ]32. 


Fig.  132  represents  the  head  of  the  femur  beneath  the  overhanging  capsule.    The  same  in 
cross-section  in  Figs.  133  and  134. 

Retracing-  the  Second  Step.  In  the  second  stage  of  disloca- 
tion the  head  left  the  region  of  the  socket  and  fell  outward  and 
downward  until  arrested  by  the  yet  untorn  part  of  the  capsule ; 
hence  to  retrace  the  second  step — lift. 


Fig.  133. 


Fig    134. 


If  the  surgeon  lifts  vertically  upward,  he  will  find  that  as  the  head 
rises  it  is  compelled  to  move  outward  to  get  from  under  the  project- 
ing rim  of  the  socket,  and  this  makes  tense  the  remnant  of  untorn 
capsule  which  checks  the  upward  progress  of  the  head  at  the  instant 
when  it  would  pass  over  the  rim  and  into  the  socket.     To  obviate 


DISLOCA  TION  0  UTWA  RD. 


139 


this  turn  the  Lent  leg  like  a  crank  outward.  This  will  compel  the 
head  and  neck  to  look  footward  (Fig.  135).  Now  tiie  limb  can  be 
lifted  to  a  level  with  the  socket,  but  on  its  arising  it  encounters  an 


Fig.  135. 


obstacle  worthy  of  our  most  serious  attention.  To  complete  the 
second  stage,  the  head  must  be  turned  inward  to  the  region  of  the 
socket,  and  now  note  that  the  tendon  of  the  hamstring  muscle  and 
its  attendant,  the  great  sacro-sciatic  nerve,  are  directly  in  the  way. 
Fig.  136. 

Fl(i.  136. 


Notice  that  thd  head  is  at  a  higher  point  than  in  Fig.  135.  and  rests  against  the  tendon  of 
the  hamstring  muscles. 


This,  I  say,  is  a  most  critical  moment,  for  the  head  must  be  turned 
into  the  region  of  the  socket,  and  has  no  other  path  than  between 


140    RED  UCTION  OF  DISL  0  CA  TIONS  B  Y  MA  NIP  ULA  TION 

the  tendon  and  the  socket.  To  do  this  while  the  limb  is  lifted  ver- 
tically with  thfe  leg  flexed  at  right  angles  to  the  femur,  which  re- 
laxes the  tendon  and  nerve,  turn  the  leg  as  a  crank  downward  and 
inward  until  the  heel  looks  footward.  Do  not  use  violence.  If  ob- 
struction be  experienced,  it  cannot  at  this  stage  lie  in  the  capsule,  it 
cannot  lie  in  anytJiing  over  which  violence  will  prevail.  It  will  lie 
in  one  of  three  things :  Either  the  head  strikes  bone,  in  which  case 
it  must  be  lifted  higher  ;  or  it  strikes  the  tendon  ;  or  the  nerve.  In 
case  it  strikes  the  tendon  it  can  be  readily  shifted,  and  the  escape  of 
the  tendon  may  be  followed  by  a  similar  escape  of  the  nerve.  I  have 
frequently  caught  them  in  succession,  and  have  so  caught  up  the 
nerve  as  to  flatten  it  over  the  head,  and  being  spread  out  twice  its 


Fig.  137 


original  size,  it  has  barred  my  progress  to  the  socket.  Therefore,  I 
urge  caution  at  this  stage,  for  if  the  nerve  be  caught  and  force  applied, 
it  (the  nerve)  has  one  of  three  destinies  before  it :  it  must  eff"ectually 
bar  all  entrance  to  the  socket,  or  slip  off  the  head  and  escape,  or 
slip  off  the  head  upon  the  neck  of  the  femur,  from  which  it  can  with 
diflBculty  be  disengaged.  I  speak  of  this  as  a  moment  of  peril,  for 
no  one,  when  he  undertakes  to  restore  a  dislocation,  can  tell  what 
degree  of  havoc  attended  the  original  traumatism,  and  whether  or  not 
the  nerve  has  been  freely  stripped  from  its  attachment  to  the  hamstring 
(biceps),  and  lies  dangling  like  a  large  cord  in  front  of  the  socket. 

If  the  iiead  has  met  with  no  obstacle  in  rotation,  it  is  now  ready 
for  the  last  step.  Please  note  the  position  of  the  head  of  the  femur : 
it  rests  upon  a  ridge  between  the  outer  and  inner  planes.     It  has 


DISLOCA TION  0 UTWA RD. 


141 


readied  its  present  position  by  being  lifted  to  a  level  with  the  socket 
and  rotated  obliquely  beneath  it  (Figs.  137,  138).  There  are  three 
courses  open  to  it  now  :  it  can  fall  outward,  pass  inward  into  the 
thyroid  depression,  or  ascend  obliquely  upward  into  the  socket. 
There  are  two  ways  for  accomplishing  a  happy  replacement  : 

Fig.  138. 


The  first  is  by  traction.  By  this  means  the  knee  is  lifted  sky- 
Avard,  which  relaxes  the  remnant  of  capsule,  while  an  assistant 
with  his  thumbs  makes  direct  pressure  upon  the  head  in  the  direc- 
tion of  the  socket.     This  may  reduce  it ;  if  not,  the  operator  may 


Fig.  139. 


bring  the  knee  down  in  extension,  the  assistant  still  keeping  up  the 
pressure  upon  the  head.  The  manoeuvre  should  not  be  attended 
with  violence  or  dispatch.  The  surgeon,  if  he  encounters  resistance, 
should  be  warned  by  it,  and  retrace  and  modify  his  course.  Usually 
the  head  will  pass  noiselessly  into  the  socket. 


142    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

The  second,  or  indirect,  method  is  to  employ  the  Y-ligament  of 
Bi^elow  as  a  fulcrum  to  drag  the  head  into  the  socket.  The  reader 
will  bear  in  mind  the  position  of  the  head:  it  lies  (Figs.  137,  138) 
below  the  socket,  and  must  be  directed  obliquely  upward  and  outward. 

If,  now,  the  knee,  with  the  leg  flexed,  be  carried  directly  down- 
3vard  in  extension,  the  remnant  of  uutorn  capsule  (Y-ligament)  will 
be  made  tense,  and  the  head  be  lifted  into  the  socket.  Should  the 
head  slip  outward  upon  the  dorsal  aspect,  it  must  be  replaced  by  lift- 
ing, and,  instead  of  extending  the  knee  directly  downward,  it  should 
be  a  little  abducted  and  then  extended.  If,  on  the  contrary,  the 
head  slipped  inAvard  into  the  thyroid  depression,  then  the  knee 
should  be  adducted  and  the  Y-ligament  tightened  a  little  by  inward 

Fig.  140. 


rotation.  (Note  the  position  of  the  foot,  Fig.  140.)  If,  now,  ex- 
tension be  made,  the  head  will  be  directed  in  the  course  of  the 
socket. 

The  reader  will  notice  that  this  employment  of  the  Y'^-ligament  is 
on  the  same  principle  that  was  given  in  the  directions  for  reducing 
dislocations  into  the  thyroid  depression,  and  the  same  cautions  need 
not  be  repeated.  Having  described  at  length  the  process  by  which 
a  femur  dislocated  outward  may  be  made  to  retrace  its  steps,  I  will 
briefly  summarize  it :  Tiie  patient  lying  supine,  the  surgeon  kneels 
by  his  side,  and  if  the  right  femur  is  dislocated,  he  seizes  the  ankle 
with  his  right  hand  and  places  the  bent  elbow  of  his  left  arm  beneath 
the  popliteal  space  :  (1)  he  now  turns  the  bent  leg  outward  by  means 
of  the  ankle  and  lifts  upward  (skyward) ;  (2)  then  turns  the  bent  leg 
inward  and  brings  the  femur  down  in  extension. 

Often  the  reduction  is  extremely  simple  and  can  be  accomplished 


DISLOCATION  OUTWARD.  143 

in  a  few  seconds  by  this  method  without  violence ;  should  it  fail,  the 
method  by  traction  should  be  adopted/ 

It  may  be  asked  at  this  point,  why  Reid's  method,  which  often 
succeeds  by  magic,  should  not  be  recommended  ?  Reid's  method  is 
through  circumduction.  He  labored  under  the  misapprehension  that 
muscular  resistance  was  the  chief  obstacle  to  reduction,  and  that  this 
was  overcome  by  relaxing  the  muscles  in  succession,  and  his  unfor- 
tunate success  in  three  instances  confirmed  him  in  his  belief  and 
checked  his  further  researches.  Bigelow  doubting  the  theory,  but 
not  knowing  the  true  one,  found  it  in  the  thick  band  of  the  capsule, 
the  ilio-femoral  ligament,  after  he  had  dissected  all  the  muscles  away. 

I  will  here  analyze  Reid's  method,  which  was  also  adopted  by 
Bigelow,  and  has  been  accepted  and  taught  almost  universally.  In 
his  first  step  he  flexes  the  leg  on  the  thigh,  and  carries  the  flexed 
knee  strongly  over  toward  the  pubes.  The  eff"ect  of  this  is  to  make 
a  fulcrum  of  the  pelvis,  which  raises  the  head  of  the  femur  to  a  level 
with  the  socket ;  now,  Avhile  the  head  is  on  a  level  Avith  the  socket, 
the  knee  is  carried  upward  toward  the  umbilicus,  and  outward  toward 
the  side.  As  the  knee  goes  upward  and  outward  the  head  passes 
downward  and  inward,  and  rises  upon  the  pelvis  below  the  socket. 
Finally  the  knee  is  brought  downward  in  extension,  the  head  passes 
into  the  socket,  and  all  is  accomplished  in  the  twinkling  of  an  eye. 

Now  the  entire  success  depends  on  the  remnant  of  untorn  capsule, 
as  Bigelow  has  pointed  out,  but  not  simply  upon  the  remnant  of  liga- 
ment, hut,  as  Agnew  lias  pointed  out,  upon  the  shortness  of  it.  For 
if  the  untorn  remnant  of  capsule  compels  the  head  to  hug  the  rim 
of  the  socket,  then  Reid's  circumductive  sweep  will  be  effectual  the 
instant  the  head  rises  upon  the  pelvis  below  the  socket  and  the  knee 
is  brought  down  in  extension. 

But  if  the  rent  in  the  capsule  is  extensive,  then  this  extensive 
sweep  will'  place  the  head  so  far  below  the  socket  that  any  attempt 
to  bring  the  head  upon  the  inner  plane  of  the  pelvis  will  be  rendered 
impossible  by  its  striking  against  the  tuberosity  of  the  ischium  and  the 
tendon  of  the  hamstring  muscles.^  While,  then,  I  caution  against 
circumduction  as  a  method  of  reduction,  as  its  success  is  based  on 
error,  and  its  employment  both  unscientific  and  attended  with  great 
hazard,  I  do  so  with  the  most  profound  respect  for  one  who,  if  not 

'  For  the  advantages  of  the  prone  position  as  a  means  of  reduction,  see  p.  147. 
-  See  Figs.  48  and  102,  and  the  accompanying  text. 


144    ^ED  UCTION  OF  DISL  0  CA  TIONS  B  Y  MANIP  ULA  TIOK 

the  pioneer  in  the  method  of  reduction  by  manipulation,  was  cer- 
tainly the  one  to  stamp  it  with  confidence,  and  arrest  the  attention 
of  the  world  upon  its  possibilities. 

I  have  said  that  the  circumductive  method  is  attended  with  danger. 
The  chief  reason  for  saying  this  is  that  in  the  employment  of  this 
plan,  one  hand  seizes  the  ankle  and  the  other  is  placed  upon  and 
directs  the  course  of  the  knee.  It  is  leverage  through  the  femur,  the 
power  being  exerted  at  the  knee  that  elevates,  i.  e.,  pries  the  head  of  the 
bone  to  a  level  with  the  socket,  and  to  this  manoeuvre  may  be  added 

Fig.  141.      ■ 


the  effect  of  the  remnant  of  untorn  capsule.  There  is  no  direct 
lifting  by  the  operator  in  this  method ;  its  employment  does  not 
follow  the  reverse  steps  of  displacement,  and  its  success  is  always  at 
the  hazard  of  catching  up  the  nerve. 

Obstacles.  If  the  methods  described  do  not  succeed,  failure  in 
recent  cases  may  be  ascribed  to : 

I.  Lack  of  skill  or  facilities  in  the  operator. 
II.  Obstacles  that  prevent  the  head  from  entering  the  socket. 

III.  Obstacles  pushed  into  the  socket  by  the  head. 

IV.  The  sciatic  nerve  hooked  over  the  neck  of  the  femur. 
I.  Lack  of  skill  or  facilities. 

Upon  this  point  I  need  have  little  to  say.  I  would,  however, 
caution  the  operator  not  to  get  desperate  and  resort  to  rash  measures 
in  the  hope  that  by  a  lucky  turn  he  may  succeed.  By  skill  and 
well-directed  measures  the  obstacles  may  be  located  and  interpreted, 
while  if  overcome  by  ignorance  or  force  it  may  not  be  to  the  advan- 


DISLOCATION  OUTWARD.  145 

tage  of  the  patient.  There  are  conditions  even  worse  than  an  unre- 
duced dislocation.  When  I  sent  a  man  home  with  the  sciatic 
stretched  across  the  neck  of  the  femur  permanent  dislocation  would 
have  been  preferable.'  When  Bigelow  restored  a  hip  to  a  partly 
filled  socket,  were  the  dry  arthritis  and  subsequent  ankylosis  an 
improvement  upon  permanent  dislocation  ?  When — as  has  twice 
happened  in  Philadelphia — the  femur  was  broken  in  an  attempt  at 
reduction,  was  fracture  added  to  dislocation  a  condition  preferable  to 
uncomplicated  dislocation  ?  or  did  the  result  reflect  creditably  upon 
the  skill  of  modern  surgery  ?  Hence  do  not,  whatever  you  do, 
become  desperate :  remember  that  obstacles  about  the  socket  are 
like  buoys  in  the  channel — they  not  only  point  to  danger  and  are  to 
be  avoided,  but,  properly  interpreted,  they  are  guides  to  port. 

Failure  may  be  the  result  of  lack  of  facilities.  Anaesthesia,  intelli- 
gent assistants,  and  fixation  are  invaluable  aids  required  by  the  most 
expert ;  therefore,  do  not  prejudice  your  case  by  a  premature  attack. 

II.  Obstacles  that  prevent  the  head  from  entering  the  socket ; 
closing  the  door  of  entrance  or  embracing  the  neck  and  holding  the 
head  in  chancery. 

a.  The  capsule.  While  I  persistently  reject  the  very  widespread 
theory  of  "  slit  in  the  capsule"  and  "buttonholing  by  the  capsule," 
and  hold  firmly  to  the  statement  previously  made,  that  the  opening 
of  exit  in  the  capsule  is  always  ample  for  the  return  of  the  head, 
I  quite  as  firmly  believe  that  the  borders  of  the  torn  capsule 
are  capable  of  effectually  resisting  efforts  at  reduction  whenever 
those  efforts  are  not  made  in  harmony  with  the  process  of  eviction. 
I  have  repeatedly  demonstrated  that  the  rent  in  the  capsule  may  be 
ample  and  afford  unobstructed  passage  for  one  method  of  reduction, 
which  by  another  mode  of  reduction  would  be  impossible.  I  have 
also  demonstrated  that  a  change  in  the  relation  of  the  femoral  head 
to  the  socket  after  dislocation  is  capable  of  creating  a  formidable 
artificial  buttonholing,  but  in  no  instance  has  resistance  withstood 
gentle,  well-directed  efforts  at  reduction. 

There  is,  however,  a  rent  in  the  capsule  that  may  defy  all  possible 
skill.  It  is  that  in  which  the  capsule  has  been  chiefly  torn  from  the 
femoral  insertion,  leaving  the  Y-ligament  as  the  only  remaining  liga- 
mentous band  of  connection  between  the  socket  and  the  base  of  the 
neck  of  the  femur.     (See  p.  52.)     Of  this  special  obstacle  Bigelow 

1  See  Reminiscences,  p.  Ix. 
10 


146    I^ED UCTION  OF  DISLOCA TIONS  B Y  MANIP ULA TION. 

says  that  '*  any  difficulty  can  be  easily  obviated  by  carrying  the 
head  of  the  bone  toward  the  opposite  side  of  the  socket  and  thus 
enlarging  the  slit."^  By  such  a  statement  Bigelow  not  only  shows 
that  he  has  never  had  practical  experimental  dealing  with  such  a 
lesion,  but  his  advice  is  that  best  suited  for  making  such  a  difficulty 
still  more  insurmountable.  Bigelow  errs  in  imagining  that  he  is 
dealing  with  a  slit.  The  rent  is  not  a  slit  in  the  long  axis  of  the  cap- 
sule, but  is  peripheral,  the  capsule  being  chiefly  torn  from  its  femoral 

Fig.  1-42. 


attachment.  It  is  the  situation  of  the  rent  that  makes  it  formidable 
— not  the  size  of  it.  The  long  detached  capsule  now  covers  the 
socket  like  a  hood,  and  no  possible  manoeuvre  can  "  enlarge  it." 
But  the  manoeuvre  suggested  by  Bigelow  will  have  this  serious  dis- 
advantage. When  the  rent  is  peripheral  at  the  base  of  the  neck — 
if  the  cuff  of  the  capsule  is  still  attached  to  surrounding  muscles, 
which  renders  reduction,  when  properly  attempted,  still  possible — 1 
have  repeatedly  in  rapid  succession  restored  such  a  dislocation  by 
direct  replacement  with  as  much  ease  as  could  be  desired ;  but  wdien 
I  have  detached  the  muscles  from  the  capsule  by  shifting  the  head 
to  the  opposite  side  of  the  socket,  as  Bigelow  directs,  I  have  found, 
upon  returning  to  the  method  previously  emploj^ed  with  success,  that 

1  The  Hip,  by  Henry  Bigelow,  pp.  33-34.    Philadelphia:  H.  C.  Lea,  1867. 


DISLOCATION  OUTWARD. 


147 


reduction  was  no  longer  possible  except  by  pushing  the  capsule,  now 
loose  and  disengaged  from  its  muscular  attachments,  before  the  head 
into  the  socket.  I  therefore  fully  agree  with  Gelle,  Malgaigne,  Gunn, 
and  others  that  this  is  a  complication  that  may  be  insurmountable. 
The  position  I  found  most  favorable  for  reduction  under  the 
circumstances  just  mentioned  is  the  one  depicted  below.  It  is 
mentioned  by  authors,  but  its  merit  has  not  been  sufficiently  dwelt 
upon.     The  subject  was  placed  prone  with  the  thigh  hanging  over 


Fig.  143. 


the  corner  of  the  table.  In  order  to  support  the  pelvis  and  sound 
limb  a  second  table  was  employed.  In  this  position  the  pelvis  can 
be  readily  secured^  —  a  condition  that  I  am  certain  contributed 
greatly  to  my  success.  The  prone  position  has  this  advantage 
over  the  supine,  in  that  it  is  assisted  by  gravity.  The  head,  when 
the  thigh  is  flexed  to  a  right  angle,  lies  directly  above  the  socket, 
and  the  weight  of  the  leg  and  thigh  has  a  natural  tendency  in  the 
right  direction.  To  favor  the  descent  of  the  head  the  ankle  may  be 
drawn  outward  and  rocked  a  little,  or  pressure  be  made  directly  over 
the  head  or  in  the  popliteal  space.     The  advantages  of  this  posi- 


1  Tlie  mode  of  fixation  I  employed  is,  of  course,  not  possible  in  actual  practice,  but  my 
success  experimentally  was  largely  attributable  to  it. 


148    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

tion  are  that  limited  circumduction  can  be  practised,  while  the  weight 
of  the  limb,  increased,  if  necessary,  will  always  be  an  aid  in  directing 
the  head  toward  the  socket. 

h.  Muscles.  Dislocations  that  are  readily  reduced,  i.  e.,  that  offer 
no  resistance,  are  probably  accompanied  with  free  laceration  of  cap- 
sule and  muscles.  As  already  mentioned,  the  outward  dislocations 
are  usually  damaging  to  the  obturator  internus,  while  if  the  disloca- 
tion were  first  thyroid  and  secondarily  dorsal,  then  the  obturator 
externus  and  quadratus  femoris  are  necessarily  torn  in  two.  It  is 
possible  for  dislocations  to  occur  without  destroying  muscular  fibre, 
i.  e.,  for  a  dislocation  to  occur  between  two  muscles  without  injuring 
either.  In  such  a  case  it  is  hardly  fair  to  say  that  the  muscles  es- 
caped by  a  lucky  dodge — it  may  be  nearer  the  truth  to  say  they 
escaped  by  their  own  power  of  resistance.  The  endurance  of  a 
strong,  live,  healthy  muscle  cannot  be  measured  by  contrasting  it 
with  a  dead,  cold,  rigid  piece  of  lean  meat.  It  is  therefore  impossi- 
ble to  arrive  at  the  difficulties  of  actual  life  by  investigations  in  the 
dissecting-room.  Probabilities  are  our  nearest  approach,  and  to 
some  of  these  I  now  ask  attention. 

Fig.  144. 


In  the  pathology  of  recent  dislocations  the  head  has  been  found  be- 
tween the  obturator  internus  and  externus.  (Fig.  144.)  Now  there 
can  be  no  possible  buttonholing  between  these  muscles,  yet  lam  per- 
suaded that  by  Reid's  method — viz.,  by  flexing  the  knee,  carrying  it 
first  toward  the  pubes,  then  up  toward  the  umbilicus,  then  upward, 
outward,  and  downward  in  extension — embarrassing  difficulties  may 


DISLOCATION  OUTWARD. 


149 


be  created.  As  the  knee  takes  its  upward  and  outward  path,  the 
head  passes  downward  and  inward  and  will  tend  to  rise  upon  the 
ischium.     Whether  through  circumduction  the  head  will  be  arrested 


Fig.  145. 


by  the  tendon  of  the  obturator  externus,  or  whether  the  quadratus 
femoris  will  become  interposed,  are  speculative,  but  not  improbable 
obstacles.  They  would  not,  however,  be  possible  if  the  method  of 
direct  replacement  were  employed,  as  mentioned  on  p.  138  et  seq. 


Fig.  146. 


Again,  the  head  of  the  femur  has  been  found  in  autopsies  between 
the  obturator  internus  and  the  pyriformis  (Fig.  145).  And  also 
above  the  pyriformis  (Fig.  146).     The  question  I  wish  to  propose  is, 


150    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

Could  either  of  these  dislocations  be  restored  by  the  usual  modern 
methods  of  manipulation?  Flexion,  circumduction,  and  rotation 
might  disengage  the  head  and  then  reduce  it — but  what  if  they  could 
not  disengage  the  head  ?  Would  the  conversion  of  a  dorsal  into  a 
thyroid  rupture  the  tendon  of  the  obturator  internus  or  that  of  the 
pyriformis  ?  Is  it  not  a  fair  inference  that  muscles  which  could  sus- 
tain, uninjured,  the  strain  put  upon  them  of  the  head  bursting 
between  them,  could  also  sustain  the  strain  of  a  much  feebler  force, 
viz.,  the  efforts  of  the  surgeon  at  manipulation  ? 

Sir  Astley  Cooper,  in  attempting  to  reduce  a  dislocation,  had  it 
suddenly  slip  into  a  position  which  he  believed  to  be  the  sciatic  notch, 

Fig.  147. 


from  which  he  could  not  extricate  it.  Surgeons  have  tried  in  vain 
to  explain  what  Sir  Astley  meant  by  his  advice  to  avoid  this  notch. 
Some  have  even  imagined  that  the  head  passed  through  the  forma- 
men  or  got  entangled  in  the  bony  notch.  Bigelow  interprets  it  that 
the  head  ascended  behind  the  tendon  of  the  obturator  internus 
(Fig.  144),  which  prevented  the  reduction  by  pulleys.  It  is  difficult 
for  me  to  understand  how  the  great  London  surgeon  could  so  long 
persevere  in  the  use  of  pulleys  if  this  most  frequent  variety  of  dis- 
location should  have  baffled  him.  Be  this  as  it  may,  Bigelow  has 
truly  said  that  no  such  imaginary  danger  can  exist  if  one  adopts 
flexion  as  a  first  step  in  reduction.  But  I  have  been  baffled  by  the 
very  methods  that  the  great  advocate  of  flexion  believed  were  invin- 
cible. 

I  ask   the  reader  now  to  turn  back  to  the  case  of  J.  II.  M., 


DISLOCATION  OUTWARD.  151 

Reminiscences,  p.  xi.,  and  read  it  carefully.  Here  Avas  a  recent  case, 
in  which  in  attempts  at  reduction  the  head  passed  repeatedly  and 
unobstructedly  from  the  outer  to  the  inner  planes  of  the  pelvis  and 
back  again,  but  when  the  head  approached  the  socket  something 
barred  it.  In  this  case  there  was  no  engagement  in  the  sciatic 
notch,  no  filling  of  the  socket,  and  no  obstruction  from  the  capsule. 
I  have  often  sought  an  explanation  of  the  difficult}^,  and  the  only 
one  that  is  in  the  least  degree  satisfactory  is  that,  in  the  dislocation 
outward,  the  head  passed  directly  between  the  obturator  internus 
and  the  pyriformis  (Fig.  147)  without  rupturing  either.  That  this 
is  possible  can  be  shown  by  reference  to  pathology,  p.  69,  Case  XI., 
but  it  cannot  be  demonstrated  upon  the  cadaver  with  stiff,  brittle,  or 
disintegrating  muscular  fibre.  While,  therefore,  I  cannot  substantiate 
the  theory  I  have  adopted,  my  reasons  for  accepting  it  are  these :  If 
those  muscles  had  the  strength  to  withstand,  without  rupture,  the 
head  bursting  between  them,  it  seems  not  incredulous  that  they  could 
withstand  a  much  weaker  force,  that  of  man's  strength  in  his  efforts 
at  reduction.  The  nature  of  the  entanglement,  which  I  denominate 
in  chancery,  seems  to  me  to  account  for  our  defeat.  If  the  head 
were  clasped  between  the  tendons  of  these  muscles,  none  of  the 
ordinary  efforts  at  reduction  would  avail.  Sir  Astley's  extension 
with  pulleys  would  do  no  good.  With  circumduction  the  tendon  of 
the  obturator  internus  might  have  been  ruptured ;  but  if  it  were  not, 
it  seems  to  be  just  in  the  position  to  bar  etfectually  all  entrance  just 
at  the  door  of  the  socket.  In  our  efforts  at  reduction  we  circum- 
ducted after  Held,  used  Despres'  method,  jerked  upward  (Bigelow), 
and  everything  that  a  full  force  of  surgeons  could,  on  two  separate 
occasions,  suggest,  but  to  no  purpose.  Acting  on  the  supposition, 
then,  that  the  head  lay  in  chancery,  i.  e.,  buttonholed  between  the 
obturator  internus  and  the  pyriformis,  I  would  suggest  the  following 
method  for  dislodgement  and  restoration  : 

By  a  glance  at  Fig.  147,  it  will  be  evident  that  neither  extension 
with  pulleys,  circumduction,  nor  rotation  could  be  instituted  in  answer 
to  the  question,  "how  to  make  the  head  retrace  its  steps."  To  do 
this  the  most  feasible  procedure  would  be  to  draw  the  head  toward 
the  socket,  but  as  the  head  rises  the  neck  will  be  grasped  all  the 
more  strongly  by  the  tendons  of  the  muscles.  Now,  while  the  knee 
is  drawn  inward  toward  the  pubes,  and  the  head  made  to  approxi- 
mate the  socket,  let  an  attendant   hold  the  head  in  this   position, 


152    RED  UCTION  OF  DISL  0 CA  TIONS  B  Y  MANIP  ULA  TION. 

while  the  surgeon,  using  the  upward  pressure  of  the  assistant  as  a 
fulcrum,  carries  the  knee  outward.  This  will  compel  the  head  to 
seek  the  interspace  between  the  muscles,  and,  once  that  it  has  passed 
through,  the  reduction  is  virtually  accomplished. 

I  desire  to  state  again  that  this  is  purely  theory,  but  a  theory  only 
put  forward  after  other  theories  of  this  special  obstacle  to  reduction 
have  been  explained  away. 

III.  Obstacles  pushed  before  the  head  into  the  socket — subluxa- 
tion. 

I  have  never  been  able  to  comprehend  what  authors  mean  by  sub- 
luxations. There  are  but  three  possible  positions  for  the  head  of 
the  femur,  viz.,  entirely  outside  of  the  socket,  on  the  rim  of  the 
socket,  and  within  the  socket.  If  the  head  lie  outside,  the  deformity 
will  be  great ;  if  it  lie  upon  the  rim,  the  deformity  will  be  greater ; 
while  the  only  position  in  which  deformity  disappears,  or  nearly  dis- 
appears, is  when  the  head  lies  in  the  socket.  In  all  the  alleged 
cases  of  subluxation  the  deformity  has  been  trifling,  and  corresponds 
to  what  I  have  experienced  when  in  experimental  work  I  have 
pushed  the  capsule  or  portions  of  the  obturator  externus  before  the 
head  into  the  socket.^ 

In  experimental  work  I  have  known  four  conditions  to  interfere 
with  complete  reduction.  By  incomplete  reduction  I  mean  any  con- 
dition that  interferes  with  normal  movements,  as  adduction  and  ex- 
tension. These  four  conditions  are  (1)  muscular  debris,  (2)  portions  of 
muscles,  (8)  inversion  of  capsule,  (4)  hooking  up  the  of  sciatic  nerve. 
All  of  these  have  been  discussed  in  the  Introductory  Study. 

In  the  first  three  the  head  is  prevented  from  sinking  to  its  normal 
depth  into  the  socket.     A  few  points  are  worthy  of  mention. 

(1)  Reduction  of  the  head  into  a  socket  cushioned  with  muscular 
or  capsular  material  will  not  be  accompanied  with  the  report  and 
sudden  succussion  that  take  place  when  naked  cartilage  strikes 
upon  naked  cartilage. 

(2)  If  the  socket  is  partially  filled,  the  normal  movements  of  ad- 
duction and  extension  will  be  interfered  with.  Such  embai'rassment 
should  be  regarded  as  a  valuable  exponent  of  the  condition  present, 
which,  if  properly  considered,  will  not  be  met  by  forced  extension  of 
the  knee,  a  resort  that  temporarily  helps  the  signs  by  mashing  or 

1  For  the  removal  of  portions  of  capsule  or  muscular  fibre  from  the  socket,  see  p.  107. 


DISLOCATION  OUTWARD.  153 

compressing  the  foreign  substance,  but  will  not  aid  the  patient  or 
facilitate  the  removal  of  the  foreign  body. 

(3)  If  the  socket  is  partially  filled,  redislocation  is  extremely 
probable.  Redislocation  may  take  place  as  the  result  of  fracture  of 
the  rim  or  imperfect  reduction,  due  to  a  partially  filled  socket. 

Points  in  regard  to  fracture  of  the  rim  : 

(a)  The  fracture  occurred  prior  to  the  dislocation.  It  could  not 
have  taken  place  after  it ;  in  other  words,  the  dislocation  was  the  re- 
sult of  the  fracture. 

{h)  No  rent  in  the  capsule  took  place  in  its  continuity,  but  the  rent 
was  through  the  fractured  rim,  i.  e.,  the  capsule  retained  its  attachment 
to  the  fragment ;   the  main  rent  was  peripheral,  not  longitudinal. 

(e)  Reduction  would  probably  be  easily  accomplished,  attended 
with  bony  crepitus ;  attended  also  with  complete  extension  and  ad- 
duction. 

(d)  No  constraint  would  attend  reduction. 

(e)  Redislocation  would  probably  attend  the  withdrawal  of  man- 
ual support,  and  be  accompanied  with  crepitus. 

Points  in  regard  to  restoration  into  a  partly  filled  socket : 

(a)  Reduction  will  be  unattended  with  succussion  or  jar.  This  is 
especially  true  when  the  material  drawn  before  the  head  is  consider- 
able. 

(b)  Constraint.  The  incomplete  reduction  will  make  tense  the  ilio- 
femoral ligament  and  arrest  the  femur  at  a  point  before  normal  ex- 
tension or  normal  adduction  is  reached. 

(c)  Crepitus  will  be  absent. 

Observation.  The  importance  of  a  proper  diagnosis  in  such  a  case 
is  apparent,  since  in  case  of  fracture  of  the  rim  rest  and  retention  will 
facilitate  perfect  recovery,  while  rest  and  retention  with  foreign 
material  in  the  socket  will  be  attended  by  inflammatory  processes  or 
redislocation  on  the  first  change  of  position. 

See  cleaning  out  the  socket,  p.  107. 

IV.    The  sciatic  nerve. 

The  implication  of  the  sciatic  nerve,  Avith  dislocations  of  the  femur, 
has  never  seriously  engaged  the  attention  of  the  medical  profession. 
In  introductory  studies  I  have  quite  fully  explained  the  anatomical 
relations  of  the  nerve  to  the  normal  and  dislocated  hip.  (P.  28.) 
I. shall  here  refer  to  the  signs  and  diagnosis,  and  suggest  a  course  of 
procedure  in  case  the  nerve  is  caught  over  the  neck  of  the  femur. 


154    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

The  possible  dangers  to  the  nerve  are  from  dislocations  outward, 
and  these  may  be  divided  into  two  classes,  viz. : 

(a)  Danger  to  the  nerve  from  the  mere  act  of  dislocation. 

(6)  Dangers  that  arise  from  the  eiforts  at  reduction. 

Danger  from  dislocation.  The  nerve  may  be  caught  up  by  the 
neck  in  the  mechanism  of  dislocation.  On  p.  62  a  pathological 
representation  is  given.  The  nerve  has  been  caught  up  with  such 
force  as  to  cause  its  complete  rupture.  Every  degree  of  impaired 
function  is  recorded,  from  pain  and  feeble  action  to  total  paralysis. 
I  believe  the  mishap  is  likely  to  occur  either  when  the  dislocation  is 
primarily  inward  and  consecutively  by  a  continuation  of  the  vulner- 
ating  force  converted  into  a  dorsal,  or  when  a  direct  dorsal  is  produced 

Fig.  148. 


by  flexion,  abduction,  and  rotation  inward.  Under  the  former  con- 
ditions, if  the  thigh  is  made  to  take  a  large  circumductive  sweep,  the 
head  will  pass  outward,  rubbing  strongly  against  the  common  tendon 
of  the  hamstring  muscles,  and  detaching,  if  not  hooking  up  the  nerve. 
Such  a  mishap  will  not  complicate  in  the  least  the  ease  of  reduction, 
but,  if  the  nerve  has  been  seriously  injured,  an  acute  neuritis  or  par- 
alysis may  ensue,  and  it  would  be  greatly  to  the  advantage  and  credit 
of  the  surgeon  if  he  could  anticipate  so  grave  a  sequel.  The  possibility 
of  ascertaining  that  the  nerve  is  hooked  over  the  neck  rests  chiefly  on 
what  can  be  felt  in  the  popliteal  space.  When  the  hip  is  in  its  socket 
the  hamstring  tendons  can  be  made  tense  and  prominent.  After 
dislocation  they  are  relaxed.  Tc  push  upon  the  knee  in  the  direc- 
tion of  the  long  axis  of  the  femur  would  still  further  relax  these 


DISLOCATION  OUTWARD. 


155 


tendons,  but  would  tend  to  tighten  the  nerve  if  it  had  been  caught 
up  over  the  neck.  (Fig.  148.)  Extension  of,  not  traction  upon, 
the  entire  limb  would  not  make  the  hamstring-  tendon  taut  if  the 
head  were  dislocated,  but  such  extension  would  make  the  nerve  more 
tense  were  it  caught  over  the  neck.  It  is,  therefore,  possible  to  as- 
certain, before  any  attempts  have  been  made  at  reduction,  that  the 
nerve  has  or  has  not  been  caught  up. 

Fig.  149. 


If  the  nerve  has  not  been  caught  up,  then  the  head  lies  outside  of 
it,  and  must  cross  or  approach  it  in  its  passage  to  the  socket  (Fig.  149). 
This  is  a  matter  of  far  more  practical  importance  than  it  has  ever  re- 
ceived, and  here  I  wish,  again,  to  call  attention  to  Reid's  method  of 
reduction.  The  underlying  principle  of  this  method  is  to  relax  the 
muscles,  and  to  accomplish  this  he  directs  the  knee  to  be  carried  over 
toward  the  pubes,  thence  toward  the  umbilicus,  thence  upward  and 
outward,  and  completing  it  by  bringing  the  limb  down  in  extension. 
Gross  and  Agnew  taught  that  the  knee  should  be  made  to  approach 
well  the  body  as  it  made  its  large  circumductive  sweep.  The  dan- 
ger in  this  consists  in  the  fact  that  the  greater  the  circle  taken  by 
the  knee  the  larger  will  be  the  circle  taken  by  the  head.  Such  a 
sweep  will   force  the  head  well  down  upon  the  tuberosity  of  the 


156    REDUCTION  OF  DISLOCATIOXS  BY  MANIPULATIOS. 

ischium,  and  as  the  knee  is  carried  outward  and  the  head  moves 
inward,  the  tendon  of  the  hamstring  muscles  will  be  struck  and 
hugged  as  the  head  passes  toward  the  socket.  (See  arrows,  Fig.  149.) 
I  have  demonstrated  (Fig.  36)  that  one  of  the  easiest,  if  not  the  easiest, 
methods  of  producing  a  dislocation  is  by  abduction,  and  if  the  disloca- 
tion is  primarily  inward,  and  consecutively  outward,  the  quadratus 
femoris^  has  been  torn  in  two  and  its  connection  to  the  nerve  destroyed. 

Fig.  150. 


Often  when  the  head  does  not  catch  up  the  nerve  in  its  outward  prog- 
ress, it  tears  it  from  its  muscular  attachments,  and  leaves  it  a  loose, 
lifeless,  dangling  rope,  barring  the  entrance  to  the  socket,  and  compel- 
ling the  head  to  strike  it  squarely,  or  slip  to  one  side  in  its  progress 
to  the  socket.  Under  such  circumstances,  if  the  large  circumduc- 
tive  sweep  were  designated  for  the  especial  purpose  of  catching  up 
the  nerve,  it  would  be  most  admirably  adapted  to  the  purpose. 

At  times  the  nerve  thus  disenojased  becomes  a  veritable  obstacle. 
Over  and  over  I  have  brought  the  head  against  the  nerve,  which,  flat- 
tened  by  pressure,  refused  to  slip  from  the  head,  and  thus  offered  a 
formidable  barrier  to  the  socket.  The  normal  nerve  is  often  the  size 
of  the  little  finger  and  may  be  flattened  to  an  inch  over  the  head,  as 
it  presses  against  it. 

When  the  nerve  is  hooked  over  the  neck  it  off'ers  no  marked  resist- 
ance to  reduction,  and  the  head  returns  to  the  socket  with  suddenness 


1  If  the  dislocations  were  directly  outward,  and  due  to  flexion,  abduction,  and  rotation  in- 
ward, the  quadratus  would  probably  be  torn  from  overstretching.  For  the  relations  of  the 
quadratus  and  nerve  to  the  socket,  see  Figs.  21  and  50. 


DISLOCATION  OUTWARD.  157 

and  succussion,  common  to  all  successful  reductions.  It  is,  therefore, 
extremely  important  in  every  case  that  the  safety  of  the  nerve  should 
be  ascertained  before  the  case  is  dismissed. 

Signs.  If  the  nerve  has  been  caught  up,  the  immediate  effect  will 
be  flexion  of  the  thigh  upon  the  pelvis,  and  of  the  leg  upon  the  thigh, 
owing  to  the  sudden  shortening  of  the  nerve.  The  change  in  the 
course  of  the  nerve  will  take  up  three  or  four  inches  of  it,  and  render 
normal  extension  impossible.  There  will  be  imparted  to  the  limb  a 
springing  motion,  which  it  can  get  in  no  other  way. 

Diagnosis.  There  are  two  conditions  that  will  produce  a  flexion  of 
the  thigh  upon  the  pelvis  as  the  result  of  imperfect  reduction,  viz. : 
the  nerve  over  the  neck  of  the  femur,  and  foreign  material  as  capsule 
or  muscular  fibre  within  the  socket,  and  both  will  be  influenced  in  the 
same  way  by  lapse  of  time.  In  both  the  flexion  will  be  greatest  imme- 
diately after  reduction.  In  case  of  the  nerve  it  will  stretch  and  let 
the  knee  down  ;  in  case  of  foreign  matter  in  the  socket  pressure  from 
the  weight  of  the  limb  will  cause  the  limb  to  descend.  The  only 
diagnostic  point  is  that  furnished  by  the  tense  cord-like  nerve  in  the 
popliteal  space,  which  can  be  made  to  rise  and  disappear  by  extension 
and  flexion  of  the  leg  on  the  thigrji. 

Treatment.  I  know  of  no  more  unpromising  task  than  that  which 
proposes  to  disengage  the  nerve  from  its  new  position,  and  in  this  the 
reader  will  agree  with  me  when  he  considers : 

1.  The  nerve  has  been  detached  from  all  its  normal  surroundino-s. 
It  is  normally  connected,  after  its  exit  from  beneath  the  pyriformis, 
to  the  gluteus  maximus,  hamstring  tendon,  the  obturator  internus, 
quadratus  femoris,  and  adductor  magnus.  From  these  it  has  been 
torn,  so  that  they  can  exercise  no  longer  any  control  over  it. 

2.  The  nerve  has  been  stretched  and  flattened  over  the  neck,  its 
sheath  torn,  its  fibres  separated. 

3.  It  lies  in  a  region  into  which  blood  has  been  poured ;  muscles 
torn  and  minced  by  eff'orts  at  reduction.  If  there  has  been  a  delay 
in  discovering  the  position  of  the  nerve,  inflammatory  products  will 
tend  to  srlue  all  the  torn  area  together. 

4.  The  only  means  available  to  disengage  the  nerve  from  the  neck 
is  to  put  the  neck  of  the  femur  in  such  a  position  that  the  nerve  will 
drop  off";  and  here  we  must  remember  that  the  adhesion  through 
fibrin  and  lymph  to  torn  muscles  will  be  far  greater  than  the  weight 


158    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

of  the  loose,  flabby  nerve,  upon  which  one  can  only  bring  gravity  to 
aid  in  detaching  and  displacing  it. 

Hopeless  as  the  situation  is,  the  operator  has  but  one  course  to 
pursue — namely : 

1.  Redislocate  the  femur;  patient  supine. 

2.  Extend  the  thigh. 

3.  Flex  the  leg  on  the  thigh  to  relax  the  nerve. 

4.  Turn  the  ankle  of  the  flexed  leg  out  until  the  leg  is  horizontal. 
The  head  will  now  look  perpendicularly  downward. 

5.  Shake,  rock,  jar,  adduct,  and  abduct,  with  a  view  to  disengage 
the  nerve  from  the  neck,  and  make  it  drop  down  below  the  level  of 
the  head. 

6.  Rotate  the  head  into  the  socket  without  making  the  nerve 
tense — i.  e.,  by  not  flexing  the  femur. 

Assuming  that  no  human  skill  can  avail  under  the  circumstances, 
I  would  suggest  the  following  course:  Cut  down  upon  the  nerve  in 
the  middle  third  of  the  thigh  above  the  upper  part  of  the  popliteal 
space,  seize  it  and  draw  upon  it.  This  will  take  up  its  slack  and 
make  the  nerve  take  a  direct  course  from  its  exit  from  the  pelvis  to 
the  point  of  traction.  This  course  will  be  below  the  level  of  the 
head.  The  head  can  now  be  detached  and  rotated  into  its  socket, 
the  nerve  itself  communicating  to  the  finger  its  release  or  any  further 
entanglement. 

Fig.  151. 


The  advantage  of  reaching  the  nerve  at  so  great  a  distance  from 
the  seat  of  injury  is  that  it  furnishes  a  clean  wound  and  easy  access 
to  the  nerve  without  admitting  air  to  the  vast  pulpified,  disintegrated 
area  of  traumatism  about  the  articulation.  After  reduction  the  nerve 
can  be  made  to  re-enter  the  wound  by  flexing  the  extended  limb. 


DISLOCATION  OUTWARD.  159 

Dislocation  of  the   Head  of  the   Femur   Complicated  with 
Fracture  of  the  Shaft. 

The  diagnosis  of  such  an  injury  will  be  difficult  in  proportion  to 
the  high  position  of  the  fracture  and  the  degree  of  swelling,  fat,  and 
muscle  surrounding  it.  Our  chief  reliance  in  detecting  fracture  must 
be  in  locating  the  upper  fragment  and  satisfying  ourselves  that  it  is 
or  is  not  affected  by  rotation  of  the  shaft.  If  the  fracture  lies  at 
the  junction  of  the  upper  and  middle  thirds,  or  just  below  the  great 
trochanter,  the  diagnosis  of  fracture  will  be  facilitated  by  the  pro- 
jection of  the  lower  end  of  the  upper  fragment.  How,  in  addition 
to  fracture,  to  make  a  diagnosis  of  dislocation  in  a  recent  case  1  am 
at  a  loss  to  state.  I  know  of  three  instances — two  in  which  the  dis- 
location was  inward  and  one  in  which  it  was  outward — in  the  practice 
of  surgeons  of  large  hospital  experience  in  which  the  element  of  dis- 
location was  entirely  overlooked.  Such  an  oversight  cannot  with 
fairness  be  classed  among  "surgical  blunders,"  nor  justified  by  ttfe 
rarity  of  the  injury,  but  must  be  classed  with  injuries  whose  precise 
nature,  owing  to  their  concealment,  cannot  be  positively  diagnosti- 
cated by  other  than  open  methods. 

In  every  case  of  which  I  have  a  knowledge  the  upper  fragment 
was  conspicuous  for  its  prominence  and  its  intractability.  In  some 
instances  of  uncomplioated  fracture  of  the  upper  third  of  the  femur 
the  upper  fragment  will  transfix  the  vasti  muscles  which  surround  it, 
and,  thus  transfixed,  will  successfully  resist  the  usual  efforts  at  appo- 
sition. In  one  such  case,  after  ansesthesia,  I  flexed  the  femur  well 
on  the  abdomen,  and  with  my  foot  in  the  fold  between  the  thigh  and 
the  abdomen  made  counter-pressure  while  I  exerted  traction  at  the 
knee  in  the  long  axis  of  the  shaft.  By  this  means  I  released  the 
fragment  from  the  transfixed  muscle,  and  when  I  brought  it  down  in 
extension  the  projection  of  the  upper  fragment  had  disappeared. 
This,  however,  would  not  be  the  case  if  dislocation  of  the  head  of  the 
femur  were  present.  Deformity  would  be  persistent.  I  therefore 
repeat,  that  while  I  know  of  no  means  other  than  palpation  for 
recognition  of  the  dislocation,  I  would  state  that  persistent  deformity 
under  ether  should  lead  to  the  suspicion  of  dislocation.^ 

1  To  facilitate  diagnosis  Agnew  once  suggested,  in  a  public  discussion  of  this  difficulty, 
the  employment  of  a  long  needle  to  explore  the  acetabulum.  Taking  advantage  of  this 
suggestion,  I  would  not  hesitate  to  make  an  incision  over  the  region  of  the  socket  suffi- 
ciently large  to  permit  of  digital  examination.  The  incision  need  not  go  beneath  the  fascia 
lata,  would  be  perfectly  harmless,  and  would  enable  the  surgeon  to  establish  beyond  perad- 
Yenture  the  presence  of  the  head  in  or  its  absence  from  the  socket. 


160    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

The  difficulties  of  reduction  of  the  dislocation  will  vary  with  the 
position  of  the  fracture.  The  reader  must  fully  appreciate  the  prin- 
ciple upon  which  success  is  based — viz.,  that  the  upper  fragment, 
the  part  extending  from  the  head  to  the  point  of  fracture,  is  our 
entire  lever  now,  and  that  the  part  of  the  femur  from  the  fracture 
to  the  knee  is  only  the  agent  through  which  we  apply  our  force. 
If,  as  in  Fig.  152,  the  head  and  neck,  i.  e.,  the  weight-arm,  were 

Fig.  152. 


three  inches  long  to  the  position  of  the  fulcrum  (the  insertion  of  the 
Y-ligament),  and  the  power-arm  only  two  inches  from  the  fulcrum 
to  the  point  of  fracture,  the  short  poAver-arm  would  act  at  a  great 
disadvantage,  whereas,  if  the  power-arm  were  equal  to  or  longer 
than  the  weight-arm,  the  power  would  act  to  better  advantage. 
Again,  the  only  mode  of  acting  upon  the  power-arm  is  through  its 
connection  with  the  long  fragment  of  bone.  The  connection,  between 
the  fragments,  partly  periosteal,  partly   tendinous,  and  partly  mus- 


DISLOGA TION  WITH  FRA CTUBE.  1 6 1 

cular,  enables  us  to  make  traction  upon  the  power-arm  in  any  direc- 
tion, but  precludes  all  efforts  at  rotation,  circumduction,  and  leverage 
through  the  agency  of  the  lower  fragment.  In  every  dislocation  of 
the  head  of  the  femur  complicated  with  fracture  of  the  shaft  the 
mechanical  powers  upon  which  we  are  to  rely  for  reduction  are : 

a,  the  power-arm  of  the  lever  extending  from  the  fracture  to  the 
fulcrum  ;  h,  the  fulcrum,  viz.,  the  ilio-femoral  ligament,  extending 
from  the  lower  iliac  spine  to  the  oblique  line  of  the  femur ;  c,  the 
weight-arm  of  the  lever,  viz.,  the  part  extending  from  the  fulcrum  to 
the  extremity  of  the  head  ;  and,  d,  the  power  exerted  upon  the  extrem- 
ity of  the  power-arm.  So  far  as  the  power  is  concerned,  it  could  be  as 
advantageously  exerted  through  a  strong  cord  attached  to  the  free 
end  of  the  short  fragment  as  through  the  part  of  the  limb  below  the 
injury.  If,  therefore,  the  operator  would  not  attempt  to  make  a 
lever  out  of  a  dangling  rope,  nor  with  it  attempt  to  rotate  or  circum- 
duct, but  confine  himself  simply  to  pulling  with  it,  he  will  under- 
stand what  I  am  insisting  upon,  viz.,  that  the  only  agency  at  our 
command  is  traction.  And  yet  with  it  this  difficulty  can  be  over- 
come. 


Reduction  of  Dislocation  of  the  Head  of  the  Femur  Inward 
Complicated  with  Fracture  of  the  Shaft  in  the  Upper 
Third, 

In  such  a  case  the  head  must  be  drawn  outward  until  it  lies  as 
near  as  possible  to  the  socket.  (Fig.  153.)  Traction  outward  may, 
with  direct  pressure,  reduce  the  head.  If  not,  the  head  must  be  held 
in  the  position  beneath  the  socket  by  an  assistant  (Fig.  154,  A)  to  pre- 
vent its  slipping  back  into  the  thyroid  depression,  while  the  surgeon 
reverses  the  direction  of  traction  and  makes  it  inward  or  obliquely 
inward  and  downward.  (Fig.  151,  B.)  The  effect  of  this  will  be  to 
place  the  lever  in  an  erect  or  semi-erect  position,  and  while  traction 
compels  the  power-arm  to  follow  it  in  the  direction  of  the  force,  the 
other  extremity  of  the  lever,  viz.,  the  weight-arm,  will  travel  in 
the  opposite  direction,  viz.,  obliquely  upward  and  outward  into  the 
socket. 


11 


1(52    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

Fig.  153. 


Fig.  154. 


Fracture  of  the  Shaft  with  Dislocation  of  the  Head  of  the 
Femur  Outward. 

The  principle  is  precisely  the  same  as  in   the  preceding.     The 
first  question  to  be  considered  is,  In  what  position  was  the  shaft  at 


DISLOOATIOy  WITH  FRACTURE. 
Fig.  155. 


163 


164    REDUCTION  OF  DISLOCATIONS  BY  MANIPULATION. 

the  instant  the  head  left  the  socket  and  fell  outward  ?  This  cannot 
be  positively  asserted  beyond  the  belief  that  it  was  nearly  vertical. 
As  the  head  fell  outward  and  lies  below  the  level  of  the  socket,  the 
head  must  be  lifted  to  a  level  with  the  socket  as  a  preliminary  step. 
There  is  but  one  way  of  raising  the  head  to  a  level  with  the  socket 
in  complications  of  this  kind,  i.  e.,  through  traction  directly  upward. 
(Fig.  157.) 

There  is  no  possible  hope  of  retracing  the  last  step  if  this  is  im- 
perfectly done  ;  hence,  in  lifting  upward  the  operator  must  be  certain 
that  the  head  follows.^  Having  lifted  the  head  to  a  level  ivith  the 
socket,  it  must  he  placed  over  it.  To  do  this,  traction  obliquely 
upward  and  inward  must  be  instituted.  (Fig.  158.)  All  this  time 
pressure  upon  the  head  or  trochanter  must  be  made  by  the  assistant 
as  in  the  previous  case — not  with  a  view  of  pushing  the  head  into 
the  socket,  but  with  a  view  of  preventing  it  from  slipping  back. 

The  head  has  now  been  brought  to  the  rim  of  the  socket,  as  in 
the  preceding  case,  and  now  as  a  last  step  the  traction  made  upon 
the  end  of  the  short  fragment  compels  the  tightening  Y-ligament  to 
drag  the  head  into  the  socket.     (Fig.  159,  p.  166.) 

Although  what  I  have  said  upon  the  reduction  of  dislocatioji  ac- 
companied with  fracture  is  based  entirely  upon  experimental  work, 
yet  the  principle  is  the  same  as  that  in  which  no  fracture  is  present, 
a  principle  that  has  established  its  correctness  through  universal 
clinical  experience. 

If  the  head  of  the  femur  in  any  dislocation  cannot  be  restored, 
what  course  shall  be  pursued  ? 

I.  Shall  the  case  be  abandoned  ? 
II.   Shall  the  surgeon  resort  to  tenotomy  ? 
III.  Shall  he  be  bolder  and  resort  to  open  measures  ? 
I.  Shall  the  case  be  abandoned  ?     If  so,  what  will  be  the  ulti- 
mate result?     Ans.  A  moderately  useful  limb  with  fixation,  proba- 
bly anchylosis.     The  efforts  at  reduction  have  pulpified  the  muscles, 
have  worn  a  bare-bone  pathway  from  thyroid  to  dorsal ;  have  scored 
and  denuded  the  head  of  its  covering;  hence  anchylosis  is  probable. 
In  abandoning  the  limb  the  surgeon  may  deposit  it  in  the  thyroid 
region,  if  he  desires  to  give  his  patient  a  useful  walking  limb,  with 

1  The  advantage  of  immobilization  of  the  pelyis  as  a  preliminarj-  step  cannot  possibly  be 
over-estimated.    See  p.  75. 


UNRED  UCED  DISL  0 CA  TION. 

Fig.  157.1 


165 


I  The  arrows  in  Figs.  157  and  158  represent  the  assistant,  who  makes  direct  pressure  upon 
the  head  and  follows  it  upward. 

11* 


166    RED  UCTION  OF  DISL  0  CA  TIONS  B  Y  MA  NIP  ULA  TION. 

trifling  limp  ;  but,  from  a  comparatively  small  experience,  I  incline 
to  the  belief  that  the  dorsal  region  will  yield  the  most  active  limb. 

II.   Shall  the  surgeon  resort  to  tenotomy  ? 

I  answer,  no.  The  obstacles  to  reduction  are  so  many  and  varied 
that  if  the  surgeon  cannot  divine  the  true  nature  or  character  of  the 
one  that  is  opposing  him,  it  is  hardly  likely  that  he  will  be  fortunate 
enough  to  overcome  it  by  such  a  measure  as  tenotomy.  The  chief 
argument  in  favor  of  tenotomy  is  that  suppuration  may  be  avoided. 

Fig.  159. 


A  represents  fixation  of  the  extremity  of  the  weight-arm,  i.  e.,  the  head  of  the  femur 
after  it  has  reached  a  favorable  position  below  the  socket  (Fig.  158).  B  represents  traction 
upon  the  extremity  of  the  power-arm. 

This  might  be  true  were  one  dealing  with  a  healthy  area,  but  under 
the  present  circumstances  there  is  danger  from  such  a  procedure.  In 
the  only  case  in  which  I  attempted  tenotomy — a  dorsal  of  eight  weeks' 
standing,  that  had  been  subjected  to  repeated  trials  at  intervals  by 
different  surgeons — I  succeeded  in  placing  the  limb  in  a  position 
simulating  reduction,  if  I  was  not  entirely  successful ;  but  within  a 
few  days,  an  extensive  abscess  formed,  requiring  open  measures. 
Were  I  to  be  called  upon  to  decide  between  abandonment  and  ten- 
otomy I  would  unhesitatingly  choose  the  former. 

III.  Shall  the  surgeon  resort  to  open  measures  ? 

If  he  has  the  courage  to  do  his  work  well  and  thoroughly,  I  be- 


UNREDUCED  DISLOCATION.  167 

lieve  that  open  work  will  not  endanger  the  life  of  the  patient,  and  is 
the  only  rational  procedure. 

Operation — Suggestion.  Place  the  patient  prone  and  locate  the 
head.  If  the  dislocation  be  dorsal,  draw  a  line  from  the  head  up- 
ward, parallel  with  the  long  axis  of  the  body.  Draw  a  second  line  at 
right  angles  to  this,  beginning  at  the  selected  point.  Bisect  this 
angle,  and  it  will  show  very  closely  the  direction  of  the  fibres  of  the 
gluteus  maximus,  which  should  be  the  direction  of  the  incision. 
These  fibres  may  be  easily  separated.  The  wound  must  be  ample  to 
admit  the  hand.  The  obstacle  must  not  only  be  overcome,  but  the 
socket  must  be  cleansed,  and  the  pulpified  muscular  structure  and 
entire  cavity  cleansed  out.  Drainage  with  gauze  for  a  day,  then  re- 
moved and  the  wound  permitted  to  heal. 


INDEX. 


Anatomy,  3 
Atmospheric  pressure,  7 

how  prevented  in  the  socket,  8 

Capsule  functions,  13 

strength  of,  17 

resists  external  rotation,  45 

size  of  rent  dependent  upon  manner  of  attack,  51 

rent  in  classified,  52 

cuff  of.  64 

torn  without  injury  to  muscles,  66 
Circumduction,  danger  of,  58 

discussed,  109  . 

Dislocations,  general  division  of,  5 
of  both  hips,  vi 
recent,  J.  H.  M.,  xi 
altered  relations  after,  71 
after  restoration,  73 
steps,  illustrated,  80 
mechanism  and  effect,  rfeume,  89 
phenomena  of,  90 
signs  and  symptoms  of,  91 
diagnosis  of,  103 
measurement  of,  105 
nomenclature  of,  113 
dorsal,  with  eversion,  133 
outward,  manipulation  of,  159 
inward,  manipulation  of,  119 

direct  method  of,  119 

indirect  method  of,  125 

Fasoia  lata,  diagnosis  in  fracture  of  neck  of  femur,  contributes   to   the 
security  of  the  hip-joint,  22 
voluntarily  relaxed  in  hip-joint  disease,  23 
Femoral  vessels,  immunity  from  danger,  18 
Femur,  head  in  socket,  9 


170  INDEX. 

Fixation,  75 

apparatus  used  in  experiments,  39 
Fulcrum,  femur  as  a,  41 

wanting,  42 

ilio-femoral  ligament  as,  43 

Hammock  function  of  fascia  lata,  23 
Hamstring  muscles,  guardians  of  sciatic  nerve,  35 
Head  of  femur,  relation  to  socket,  9 

Ilio-femoral  ligament,  13 

never  torn  from  its  subspinous  attachment,  51 
Ischio-femoral  ligament,  15 

Lesions  in  capsule,  49 

Lever,  when  femur  can  be  used  as,  40 

Ligamentum  teres  brings  thin  scale  of  bone  away,  67 

Muscles,  how  torn  in  dislocations,  56 
obturator  and  quadratus,  torn,  59 
lesions,  resume,  59 

obturator  internus,  tendon  torn  from,  68 
untorn  in  dorsal  dislocation,  69 

Pathology,  (51 

Pectineo-femoral  ligament,  13 

Pelvis,  fixation  of,  for  experimental  work  defended,  38 

shape  of,  4 

fracture  of,  due  to  efforts  at  dislocation,  46 
Planes  of  pelvis,  5 
Propositions,  2 
Pubo-femoral  ligaments,  14 

Reduction,  aids  and  obstacles  in,  73 
Keminiscences,  v 
Rotation  discussed,  10 

Sciatic  nerve  hooked  up  through  reduction,  Dr.  Koons'  case,  viii 
Dr.  Johnson's  case,  x 

relations  to  dislocations  of,  28 

protected  against  overstretching,  28 

hooked  over  neck,  mechanism  of,  33 

how  influenced  by  abduction  and  adduction,  34 

caught,  pathology,  62 

manipulation  to  remove,  156 
Socket  divided  into  equal  parts,  3 

situation  of, 


INDEX.  Ill 

Socket  felt  after  dislocation,  5 

security  of,  against  displacements,  7 

retentive  function  due  to  atmospheric  pressure,  7 

retentive  function  distributed  between  suction-ligaments  and  muscles,  7 

security  of,  7 

vacuum  prevented,  8 

cleaning  out,  107 
Sucker  ligament,  7 
Suction.     [See  Atmospheric  Pressure.) 

Teres,  ligamentum,  anatomy  of,  9 

functions  of,  10 

how  torn  from  the  head,  11 

summary  of  functions  of,  12 
Thrust,  theory  opposed,  84 

Vacuum  in  socket  prevented,  7 

Y-LlGAMENT,  13 

Prof.  Bigelow's  description  of,  1 8 


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